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SERVICE REOUEST (Eli 00 61) Revised 8/23/93 <br /> FACILITY ID M RECORD IDM INVOICE M <br /> FACILITY NAME' BILLING PARTY / N <br /> SITE ADDRESS <br /> CITY � . CA ZIP 9�t�S <br /> OINFR/OPERATOR BILIING PARTY Y / N <br /> DBA Wi ///Ill��, Lb PHONE Mt IQ � <br /> ADDRESS '�' �V <br /> �J PHONE M2 ( ) <br /> CITY STATE `�V" _ ZIP 7q <br /> p pPN M — {=Lard Use Application M <br /> Dlst Location Code <br /> TUR and/or <br /> SERVICE <br /> SERVICE RF.Ol1E SLUR iMtll" M1 BILLING PARTY Y / N <br /> DBA AI PHONE Mi <br /> MAILING ADDRESS FAX M <br /> CITY STATE Wim+ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of Same, acknowledge that all site a /'o specific <br /> PIIS/EHD hourly charges associated with this facility or activity will be billed to the party identifiel) . tl J1199I PARTY on <br /> Pogo 1 of this form. �t-JO �wv /JJ <br /> sAty <br /> PUO g# UI � al l SAN <br /> I also certify that I have Prepared this oppl lest ion and that the work to be performed will be d�'PWl1 rj�,) q(N�TRVECEsiOp <br /> JDAOUIN COUNTY Ordinance Codes and Standards, State and F�eddee�rnt laws. J HDTV <br /> APPLICANT'S�{SIGNATURE v_ / T r <br /> MAWACT PO R-S��L o/L Z'B.J <br /> Title: J)Aj CZ — "'*'� Date: / Z12 Z/4Z . <br /> AUIHn1117ATION 10 RELEASE. INFORMATION: In addition to the above, when appticobte. I, the owner, operator or agent of same, of <br /> the property located at the nbove site address hereby authorize the release of any and all results, geotechnical date and/or <br /> ermiromaental/site assessnent information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is evniloble and at the snee tine it is provided to me or my representative. , <br /> Nature of Service Request: LAaA1 n Service Code <br /> rg � <br /> Assigned toIAI�9.,4mdeX=,_ Enployee M _ Date 12/—L 3 <br /> Date Service Comleted I_/ / Further Action Required: Y / N PROGRAM ELEMENT 3 <br /> Fee Anexunt Amount Paid Date of Papnent Paymnt Type Receipt M Check M Recvd By <br /> 73 4_ a34 - �� 1a31y� ✓ l03 t� �. <br /> ( 51RV ACCT �'� / ,/ "1 I UNIT CLK <br />