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• SERVICE REQUEST . CEN 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # DI G4- <br /> Q LLL�.:. '���✓✓✓ <br /> FACILITY NAME �C>� �`!/Y�/L�JT/' � r/ l�( 'Y //lC /h�Y1�i BILL, L �a N <br /> SITE ADDRESS <br /> CITY r- C4 /0" CA ZIP C/S3a� EN�AEHEF`TH <br /> rNv1R�NM�SERVICES <br /> OWNER/OPERATOR LL/� ��/ >�' �/UVJ �� BILLING PARTY Y / N <br /> DBA PHONE #1 (C'2� ) - 6691,6 <br /> ADDRESS Ci Z& S �v/✓ PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> IF BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING PARTY Y / N <br /> DBA PHONE #1 <br /> MAILING ADDRESS FAX # ( ) <br /> CITY NJ STATE ZIP <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 /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> OAQUIN COUNTY Ordinance Codes and Standards, State a ederal laws. <br /> PPLICANT'S SIGNATURE Z <br /> r <br /> itle• t e5 / %7 ate• ` < <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> nvironmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: Service Code <br /> Assigned to ! _ Employee # Date <br /> / <br /> Date Service Completed 7 /—,a2 8/ _ Further Action Required: Y / N PROGRAM ELEMENT !110 Cy <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPV _/ / ACCT / / UNIT CLK _/ / <br />