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SERVICE REQUEST (SERVREO) Revised 9/23/93 <br />FACILITY 10 0 RECORD ID H INVOICE K <br />_Cl) <br />rACILItY NAM: "Lf 9 64A-) <br />j� /E� gi Ll luD PARTr <br />�/1'"'r / u <br />SITE ADDRESS oL 3q L) I `ter` -rig "'t4l <br />CITY A4 C% ZIP L 5-3 '7 `0 <br />n,MFR/OPERATOR <br />DRA <br />ADDRESS <br />CITY <br />E—ArN A = <br />STATE <br />Use Application R = <br />CONTRAC10R and/or <br />SFRVICE REOUESTOR w F'/N (// R-�n-)FYI i/YL44,1 Y)l� <br />DPA <br />ZIP <br />BILLING PARTY T / N <br />PHONE M1 ( ) <br />PHONE M2 ( ) <br />BOS Dlet Location Code <br />BILLING PARTY / N <br />PHONE Al (> LN ) <br />MAILING ADDRESS C�1J <br />LRb(-II ,1�;(-rDtA) � 'k�(,ii �l E,". OLS 0 !;'-I /—TAX / <br />CITY � (�t4M STATE O� 4 <br />ZIP '7 -S{a 3 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of sane, acknowledge that ell site and/or project specific <br />PHS/EHD hourly chargee associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br />Page t of this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and federal laws. <br />APPLICANT'S SIGNATURE <br />Title <br />AIItHORIZATION 10 RELEASE INTOMATIONt In additlon to the above, when applicable, 1, the owner, operator or agent of same, of <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 IR available and at the sane time It IS provided to me or my representative. <br />Nature of Service Request- J !: U if' E' {—L F <br />j - f <br />Assigned tv �"( I I Sriet. /L) Employee M 0 i <br />14 <br />Dote service completed _/ <br />Further Action Required- Y / N <br />Service Code <br />Date / / <br />PROGRAM ELEMENT J(, <br />fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Recelpt K <br />Check A <br />Recvd By <br />-�3y,00 <br />RFHS I _/_/_I SUPV 1 _1 /_ I ACCT I /_ / I UNIT CLK I _/_/_ <br />