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SERVICE REQUEST (SERVREQ) Revised 8/23193 ,,s= rACILITY ID # RECORD ID # INVOICE FACILITY NAME S -s S L' 1-7 �� Y P V�� S BILLING PARTYY / N SITE ADDRESS 2 3-1 �' w CITY CA ZIP l %� OWNER/OPERATOR r •-Q BILLING PARTY Y /'N DBA S CIL PHONE #1 ( ) ADDRESS lVu�LY/� •�i • SZ1� PHONE 02 ( ) CITY STATE �' ZIP 9 fl3 APN N � Land Use Application ak F [ES Dist Location Code or nd/ a CONTRACTOR SERVICE OR and/or =BILLING PARTY Y / N UESTOR DBA PHONE 01 MAILING ADDRESS FAX # ( ) CITY STAT ZIP BILLING ACKNOWLEDGEMENT: I the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PNS/EHD hourly charges ass ci d with this facility or activity will be billed to the party identified as the BILLING PARTY on Pape 1 of this form 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 Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Title:_ Date: -?,-k3� - AUTHORIZATION TOO 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 envirormental/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. s Nature of Service Request: Service Code Assigned to &)u �1- _ Employee # d 3�, 'i Date --3-j 18 /� Date Service Completed .3 Further Action Required: Y / N PROGRAM ELEMENT 4'C),If Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By RENS / l V / G SUPV �f 6 / �� ACCTLT UNIT UNIT CLK