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SERVICE REQUEST CEH 00 61) Revised 8/23/93 FACILITY ID RECORD ID R ) l b INVOICE FACILITY NAMEBI �r�//V / LLING PARTY Y / N SITE ADDRESS 2--2 -7 SOLI/1- �VE6Z CITY 23A/V 7—A CA ZIP OWNER/OPERATOR L/ -7 k E e,4 2 BILLING PARTY Y / 4 DBA PHONE #1 ( ) ADDRESS PHONE 92 ( ) - CITY STATE ZIP r APN # UP, d Use Application # I ..3 S BOS Dist Location Code CONTRACTOR and/or SERVICE REQUESTOR =BILLING PARTY DBA V/`� "`��/��/ / PHONE #1 ( )_LZ2_' 7%l0 MAILING ADDRESSFAX # ( ) CITY �l r/ZL-D .� STATE �_ ZIP � -3-5- BILLING 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 'oe billed to the party identified as the BILLING PARTY on Page 1 of this form. I also certify that I have prepared tfiis application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Orcinance Codes an t ards, S e and Federal Laws. APPLICANT'S SIGNATURE : P� 7 1998 Title: WI1 15�c— Date: �/ AUTHORIZATION 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: 2✓ Service Code S`\ S� Assigned to z�-�^ �} Employee # Date Date Service Comoleted / / Further Action Required: Y / 4 PROGRAM ELEMENT -,2� • Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Redd By 21 REHS _/ / SUPV _/ / ( ACCT _/ / UNIT CLK _/ /