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SERVICE REQUEST (SERVREQ) Revised 8/23/93 FACILITY ID N F RECORD ID N INVOICE N rACILITY NAME PI M GN TSL f)A LR2 J CANNCA-Y /.»STA NILLINO PARTY / N SITE ADDRESS 46204 IA) Rf�N TLI N R►' -- CiTY -rP-AC CA ZIP '/ � 37'b JnJNFR/OPERATOR ,�{�,E �n'1 FIM I J� L BILLING PARTY t 7—Y ) / N DBA PIM F lq r t:- L n j J PHONE N1 ADDRESS 40204 ' W '' t_/R A N TL I Al L= PHONE 02 ( ) CITY ERA CI STATECI p z `3 76 F APN N F Lend Use Application N [Bog Dist Location Code q CONTRACTOR and/or SFRVICE RFQUESTOR Al E BILLING PARTY Y / N DBA PHONE N1 (0?0!� ) MAILING ADDRESS FAX N p201 )-13-S- 076 CITY STATE ZIP RILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of some, acknowledge that alt site and/or project specific PNS/ENO 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. I nlso certify that I have prepared this application and that the work to be performed will be done In accordance with ell SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Title: Date: AUi11ORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of now. of the property located at the above site address hereby authorize the releese of any and ell results, geotechnical date and/or environmental/aite assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it Is available and at the some time It is provided to me or my representative. Nature of Service Request: *60446 IJA STS PC-A)M I( FCS Service Code Assigned to R A J(A /h A KH-6 W Employee N Date bate Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 4 6 Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By RFHS 6 SUPV !/ / ACCT _/ / UNIT CLK _/ /