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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> EC <br /> ITY ID # RECORD ID # r� INVOICE # 3 <br /> 7_.. <br /> FACILITY NAME ?fJ"n4 L / /� 1 P�t�Pi�� BILLING PARTY Y / N <br /> SITE ADDRESS Z <br /> CITYT mss' ® CA ZIPd <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA ems' PHONE #1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP /C, Z 2�0 <br /> APN # and Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> ICE REQUESTOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS FAX # ( ) <br /> CITY 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 /> rJAfML N3 <br /> I also certify that I have prepared this application and that the work to be performed wi RFiC45W V"ccordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> NOV <br /> - 11996 <br /> APPLICANT'S SIGNATURE <br /> N COUNTY <br /> H SERVICES <br /> Title: fi'tf��j � Date: - ` <br /> DIVISION <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 /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same timeitis provided to/me or my representative. <br /> Nature of Service Request: C c3i>1�t-t/1i�7[b4,1 Service Code ^/ . / 1 <br /> Assigned to Employee # > Date <br /> Date Service Completed —/—/_ Further Action Required: Y / N PROGRAM ELEMENT b <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 7 H00 <br /> SUPV _/ / ACCT ��/ / f' UNIT <br /> Ai-r— <br />