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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # ,1 RECORD IIID # INVOICE # <br /> FACILITY MME'-1;:L(4 l/'�\ �ffiiC 'Y \ 1�111�"l L�1 ` �l{r.��l,Lyl7 BILLING PARTY Y / N <br /> SITE ADDRESS 'Z-)S -C)n C7 <br /> CITY CA zip(( <br /> OWNER/OPERATOR T'M ( I -r <br /> ( aa »I C q-. l ��y'��-�A C 116 V7 BILLING PARTY / N <br /> DBA S(P7' PHONE #1 ( ) <br /> ADDRESS SI l� PHONE #2 ( ) <br /> CITY STATE ZIP <br /> ppN # P Land Use Application # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or r <br /> SERVICE REQUESTOR GIM BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS I�7L J-4- 3-11, FAX # ( ) <br /> CITY M od ec,+-D STATE �i ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of sane, acknowledge that all site and/or project specific <br /> PHS/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 /> 1 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: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition 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 is available and at the same)I time it is provided to me or my representative. <br /> Nature of Service Request: V S 1 �G'(Yln\12 Service Code 3 <br /> Assigned to Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT d3 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 3� �o 14 <br /> REHS � / l "IS SUPV UNIT CLK _/_J_ <br />