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—-- SERVICE REQUEST (SERVREG) Revised 5/13/93 FACILITY IO # U:ZRECORD 10 # BILLING PARTY Y / N FACILITY NAME C HARK' iQz)4p _0'r lz. SITE ADDRESS CITY CA ZIP OWNER/OPERATOR b `f r/� �7 BILLING PARTY / N DBA �l��t t . �5 _ 7--IJG PHONE 91 ( �c� )t-77 O 8460 ADDRESS /��%� G'-NyGHJ�D !�.'FY PHONE 02 ( ) CITY "[?.X-Isrb STATE ZIP APN N Census --------- BOS Dist Location Code City Code ------ � i � CONTRACTOR and/or SERVICE REOUESTOR BILLING PARTY Y / H DBA PHONE 01 ( ) MAILING ADDRESS FAX # ( ) CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD 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. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with alt SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE2✓7 ��+o Title: Date: ( — AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator er agent of shw, 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 DIVISICU as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: (3yl �{ /` 'y Service Code: Assigned to C-nAY"11;c ;t,.�r Employee It: b Z8 pate: 'Pi-1 Date Service Completed: � Further Action Required: PROGRAM ELEMENT `7 V,`T/Z, Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check 0 Recvd By UNIT ClK RENS _/ / SUPV / L / 9� ACCT /� -� /