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SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # L INVOICE # <br /> FACILITY NAME �W 56 f�JC(�i< T` BILLING PARTY Y <br /> SITE ADDRESS `Ll J �0041-il <br /> CITY CA ZIP <br /> OLINER/OPERATOR <br /> DBA A k PHONE <br /> ADDRESS h\- <br /> Y-� PHONE #2 ( - <br /> CITY STATE ZIPZ— # <br /> APN # � and Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> 9FRVIfF 11FRl1F_S1AR ' /,�p��/.�',,,,,,,,�,a,,F BILLING PARTY Y 2 M <br /> DBA M Ll�N CGI (� (1,)�—�IA1744Q,�ONE #1 <br /> ING ADDRESS f36^ SS FAX # <br /> CITY �� 1 /ATE ZIP % o`YJ <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, o rator 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 /> also certify that I have prepared this applic ion aril that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, tete and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title• Date: <br /> AUTHORIZATION TO RELEASE INFORMA/sie <br /> n addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> he property located at the abovddress hereby authorize the release of any and all results, geotechnical data and/or <br /> envirormental/site assessment inn to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same is provided to me or my representative. <br /> Nature of Service Request: a Service Code <br /> Assigned to Employee # Dq 1) Q) Date <br /> Date Service Completed / _/ Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount /Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 47 oc) <br /> L <br /> S / / SUPV / / ACCT 1 UNIT CLK / / <br />