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• SERVICE REQUEST is (EH 00 61) Revised 8/23/93 FACILITY ID # I RECORD ID # O C) q p2 9 INVOICE # FACILITY NAME I V BILLING PARTY Y / N SITE ADDRESS CITY —� i !�'lA CA ZIP OWNER/OPERATOR �� S,l U. L�yr% � BILLING PARTY Y / N DBA PHONE #1 ADDRESS t4,.,2 Lk V-V V`r-)r, PHONE #2 ( ) CITY LA STATE t ' ZIP F PN # Land Use Application # Z--I — ! 7CJ' A n =BOSDist Location Code CONTRACTOR and/or CJ SERVICE REQUESTOR �M BILLING PARTY Y / N DBA PHONE #1 ( ) MAILING ADDRESS C.�P {� 6c S' FAX # CITY STATE ZIP ILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or ,prAj* Tlocjfic HS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the B 1W-0AAf'Y on Page 1 of this form. JUN 2 51996 I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance ea and Standards, and F rat taus. SAN JOAQUIN COUNTY S PU"BLIC HEALTH SERVICES APPLICANT'S SIGNATURE _ [ NT AL HEALTH NVIS10I Title: Q^ LN, P t Ir S E=e Date: UTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: Service Code o� 1 Assigned to Employee # Date _/ ...... Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT `I Z Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS f / /2 SUPV _/ / ACCT / / UNIT CLKpy to0 t