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s,,eooNz2 _- - SERVICE REQUEST r-- + �, (SERVREO) Revleed 9/2303 FACILITY Ib R RECORD Ib N INVOICE N ,ILLI,, PARYY y I'ACILItY NAME SITE ADDRESS rv� � �' [[�� !,+ CITY �1'�O C..I�-'F-� Fy ZIP �P S rAA1FR/OPERA TDR E!J Y1ti• -e BILLING PARTY PHONE N1 DBA fj ry ADDRESS r 0 �O/k, -a'o q1 PHONE r02 STI' ( ) CITY G-OS CcIao5 STATE �`-' ZIP l 2-L4 _ .._APR N Lard Use Application N BOS Dist Location Code CONTRACtOR mrd/or SFRVICE REDUESTOR DBA �f� _ VT A✓Le�IUC 671 _ PHONE N1 (ICji) � �J' MAILING ADDRESS k J�r� I:AX N (jZL7-) ��' CITY STATE ZIP 9s�4 I 432s I/ BILLING ACKNOULEDGEMENTt I, the undersigned owner, operator or agent of none, acknowledge that all alta and/or project specific rils/END hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on Poge t of this form. I nlao certify that I have prepared this application end that the work to be performed will be done In accordance with all SAN JOAQUIN COUNTY ordinance Codes end Standards, State and Federal laws. APPLICANT'S SIGNATURE : title: Date- AUTHORIZATION To RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 1t Is provided to me or my representative. Nature of Service Request! �Q 'YG� /��/�J'bZ/k-� TE/jy�NI! f Service Code J. Asslgned to Employee N I/-3 Date /- I-note Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT 3 - d U fee Amount Amount Paid Date of Payment Payment Type Recelpt N Check N Recvd By $,lam 68 7739/ I I I3�5 RFHS _/ / sup., _/_/_ ACCT /_�' / UNIT CLK _/ /.