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• SERVICE REQUEST • (SERVREQ) Revised 8/23/93 <br /> FACILIT:YI D # �03 I RECORD ID # INVOICE <br /> -- / <br /> rACILITY NAME I W1- Z s BILLING PARTY Y / N <br /> SITE ADDRESS O ✓2- ,^ I , -t lQ I U <br /> CITY --7—y2-eel CA ZIP 5- 3 76 i <br /> OWNFR/OPERATOR J Q t ( L^' + BILLING PARTY Y / N <br /> DBA PHONE #i ( ) <br /> ADDRESS PHONE #2 00 9 )S36 --Q-21 <br /> CITY STATE ZIP <br /> -ArN # Land Use Application # <br /> IF BOS at 1;2 /6 Location Code q <br /> CONTP,ACTOR end/or <br /> SFRVICE REQUESTOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS FAX # ( ) <br /> CITY STATE ZIP <br /> i <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, 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 /> Pn9p 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 <br /> Title- Date: `� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent o same, of <br /> the property located at the above site address hereby authorize the release of any and all resul eotechn ata and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTI DIVISION as soon as <br /> It is available and at the some time it Is provided to me or my representative. <br /> Nature of Service Request: S• W � e ![ a, ^�c ��- Service Code 2 <br /> Assigned to , Employee #- C Date <br /> Date Service Completed / / Further Action Required: Y / N PROGR ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 3 v <br /> RFHS / CS// SUPV C / ACCT / / UNIT CLK _/ / <br />