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Ll SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY NAME OUl4z- ST -e Jtii,li•,2i * (2( SITE ADDRESS I' `� T E>UISe AyF CITY MA-tJZEZA, CA zip L s336,7, BILLING PARTY Y / N ER/OPERATOR Qu � ��'� �75 (�C BILLING PARTY / N DBA CSCE / PHONE #1 ( Q- ADDRESS RC). 1V�'K S`7 `FS PHONE #2 ( V& ) 3-731- CITY 731-CITY 1 �� STATE C� ZIP APN #Land Use Application # Z �� ^ QiO 43 �BiDist Location Code1 J CONTRACTOR and/or k/ E L SERVICE REOUESTOR M 'f-� BILLING PARTY Y 1k, ��- WAt-'��1 �'`N�(� � PHONE #1 0110 ) 3%3- (d8 MAILING ADDRESS V c> �x ��Z S FAX # CITY We757 S1ATE C -A ZIP RS�� BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance C n and S Kncerds, State and Federal laws. ��i APPLICANT'S SIGNATURE- Title• E}2C�(. �rT �% &JUls Date: L� . AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: Service Code Assigned to ��`� t-�N Employee # ''22-75 Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 1 - Fee A Amount Paid Date of Payment RECORD ID # � ` - 1 l INVOICE # Check # FACILITY ID # FACILITY NAME OUl4z- ST -e Jtii,li•,2i * (2( SITE ADDRESS I' `� T E>UISe AyF CITY MA-tJZEZA, CA zip L s336,7, BILLING PARTY Y / N ER/OPERATOR Qu � ��'� �75 (�C BILLING PARTY / N DBA CSCE / PHONE #1 ( Q- ADDRESS RC). 1V�'K S`7 `FS PHONE #2 ( V& ) 3-731- CITY 731-CITY 1 �� STATE C� ZIP APN #Land Use Application # Z �� ^ QiO 43 �BiDist Location Code1 J CONTRACTOR and/or k/ E L SERVICE REOUESTOR M 'f-� BILLING PARTY Y 1k, ��- WAt-'��1 �'`N�(� � PHONE #1 0110 ) 3%3- (d8 MAILING ADDRESS V c> �x ��Z S FAX # CITY We757 S1ATE C -A ZIP RS�� BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance C n and S Kncerds, State and Federal laws. ��i APPLICANT'S SIGNATURE- Title• E}2C�(. �rT �% &JUls Date: L� . AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: Service Code Assigned to ��`� t-�N Employee # ''22-75 Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 1 - Fee A Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By �r3 tigii--w Cv__ SUPV RENS / /