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1, FACILITF___ FACILITY NAME SITE ADDRESS y CITY' 4b RECORD ID # CA ZIP (< Zoz OPERATOR \rC Pt-,A,R-:� I l L-��'�r'L BILLING PARTY /AY / H DBA �-n PHONE #1 ADDRES;3G 6'7 �C'j ��Q it AO PHONE 92 ( i CI Y/- ��-�-rC�� STAT 2[P APN # p Lard Use Application # IBOB Dist Location Code CONTRACTOR 84(11 \ SERVICE REOUESTOR DBA �— / PHONE #1 MAILING ADDRESS _ 6 �-y FAX# (3 A �--YK3 y CI TY� "'S STATE`\A ZIP � ZO % BILLING ACKNOWLEDGEMENT: 1, the Undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated wit -this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. r I also certify that I ha a prepar this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Standards, State and Federal Lawsa \ APPLICANT'S SIGNATURE : /11/ i Title✓ Date: AUTHORIZATION TO RELEASE INFORMATION: In additim to the above, when applicable, I, the owner, operator or agefliof same, of I the property Located at the above site address hereby authorize the release of any and all results, geotechnical data and/or nm enviroental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONNNENTAL H LTH DIV ION as soon as /yp it is av_q,jj lei_ representative. ��9/ /F%1 lc = 6,?'fl %- of Service Request: Assigned to Date Service Completed Employee # Further Action Required: Y / N Service Cade Date _/ 1 PROGRAM ELEMENT ,�2 �) --� U Fee Amount Amount Paid SERVICE REQUEST-. 24 - O (SER 0) Rev?sed 8/23/93 0 2 %NVOICE # Recvd By B)LLING P RTY / I CA ZIP (< Zoz OPERATOR \rC Pt-,A,R-:� I l L-��'�r'L BILLING PARTY /AY / H DBA �-n PHONE #1 ADDRES;3G 6'7 �C'j ��Q it AO PHONE 92 ( i CI Y/- ��-�-rC�� STAT 2[P APN # p Lard Use Application # IBOB Dist Location Code CONTRACTOR 84(11 \ SERVICE REOUESTOR DBA �— / PHONE #1 MAILING ADDRESS _ 6 �-y FAX# (3 A �--YK3 y CI TY� "'S STATE`\A ZIP � ZO % BILLING ACKNOWLEDGEMENT: 1, the Undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated wit -this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. r I also certify that I ha a prepar this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Standards, State and Federal Lawsa \ APPLICANT'S SIGNATURE : /11/ i Title✓ Date: AUTHORIZATION TO RELEASE INFORMATION: In additim to the above, when applicable, I, the owner, operator or agefliof same, of I the property Located at the above site address hereby authorize the release of any and all results, geotechnical data and/or nm enviroental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONNNENTAL H LTH DIV ION as soon as /yp it is av_q,jj lei_ representative. ��9/ /F%1 lc = 6,?'fl %- of Service Request: Assigned to Date Service Completed Employee # Further Action Required: Y / N Service Cade Date _/ 1 PROGRAM ELEMENT ,�2 �) --� U Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By T56-ao C� ��I 3u �, 4 RENS_/_/_ I SUPV _�__ ACCT �� / 1 /__ 9 UNIT CLK S6,a