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SERVICE REQUEST (EH 00 613 Revised 8/23/93 <br />FACILITY ID # RECORD ID # n INVOICE <br />FACILITY NAME G;H9-(a I"%, BILLING PARTYY / N� <br />SITE ADDRESS �O4033 i j-1F—`t IG AV <br />CITY T®� CA ZIPSZ®7 <br />OWNER ERATOR! <br />p BILLING PARTY / N <br />DBA CH'�VI� 14 ShuCTS CC- PHONE #1 (,5J0 ,) Z -9 SW <br />ADDRESS P ib®;oc. 6(nn4- PHONE #2 C ) <br />CITY STATE CA ZIP %T5y3 <br />i APN # Land Use Application # <br />Eist Location Code <br />CONTRACTOR and/or tt' <br />SERVICE REQUESTOR _ F W E tC;11 BILLING PARTY -Y /. N <br />DBA �N� 1 � aNS Cd ti{C�V l� PHONE #1 ( g_J� <br />20 p p3c ! 0 3 f 4P pf `f'j 2.+f <br />MAILING ADDRESS 12Z� �• �ANC� �Fl+ ° FAX-bcy # ( ) <br />CITY Si: N STATE CAZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />Page 1 of this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br />APPLICANT'S SIGNATURE • _ �'-�� R(C�T �, C.9� <br />Title: PFZDJ . M G [2 . Date: G <br />AUTHORIZATION TO RELEASE INFORMATION: In addition torhIlmove, wfien applicabUtrip; a owner, operator or agent of same, of <br />the property located at the above site address hereby authorize ��t�le�e any and all results, geotechnicat data and/or <br />ms <br />enviroental/site assessment information to SAN JOAQUIN COUlWF68 H SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is available and at the sane time it is provided ent ti*e,, l—'TH f <br />Nature of Service Request: • hA •r1a E'e ra Service Code <br />Assigned to Employee # 1 Date _/_ ,/ <br />Date Service Completed _�_/ Further Action Required: Y / N PROGRAM ELEMEN <br />f Ae <br />Fee Amount Amount Paid Date of Payment Payment Tge Receipt # Check # Recvd By <br />-3'6 3 �f• 6' Jo-ty -�1-7 <br />RENSACCT /�/ UNIT CLK ®/_� <br />