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SERVICE REQUEST CEH 00 61) Revised 8/23/93 <br /> FACILITY ID'# 00 3/ RECORD ID # INVOICE <br /> FACILITY NAME /y I-I ` �RTY Y / <br /> SITE ADDRESS -974 <br /> ? lL G S% L�/T /i� / 1/G r ��/�i7J I/ 7 <br /> CITY H'I� Y CA ZIP % �3 / <br /> OWNER/OPERATOR z!�7X4 NI- G 6J1,,4 f 11 BILLING PARTY Y / <br /> DBA A�//i A J PHONE #1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or L/ <br /> SERVICE REQUESTOR �� �1W`S Al l/�G BILLING PARTY Ye / N <br /> DBA PHONE #1 <br /> MAILING ADDRESS FAX # <br /> CITY l /iii STATE IM ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done ip,.,4cF4P ;with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. <br /> APPLICANT'S SIGNATURE OCT 311996 <br /> SAN JOAQUIN COUNTY <br /> Title: �` .� — �'w1 f'�E��r � Date: �U/�,/ 96 LI HgSERVICES <br /> q�r� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owrelr,OopmePATALo�F�g6r1t RVIIWNf <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH 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: / Service Code t4 <br /> Assigned to D c�� W,�Xa u Employee # �' q o3 Date -j C <br /> Date Service Completed 1 / Further Action Required: Y / N PROGRAM ELEMENT O <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPV _/ / ACCT / _/. _ UNIT CLK _/ / <br />