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SERVICE REQUEST _ (SERVRED) Revised 81211"fACILITY ID 0 d' (J / RECORD ID @(1 F) I� 1— pNV01 CE R <br /> FACILITY NAME \ �C� LLYI/iS'J lit/n 0� VIL.�X_� BILLING PARTY Y / N <br /> n <br /> SITE ADDRESS / <br /> CITY ./ _ CA ZIP _ <br /> OWNER/OPERATOR _� \�Q� D � L __ BILLING PARTY Y / N <br /> PAYMENT <br /> DBA RECEIVED __ PHONE M1 ( ) <br /> ADDRESS MAY 10 1095 _ PHONE 02 <br /> SAN JOAQWN, COUNTY <br /> CITY pOglr, ALTHSprjfiCFS <br /> FAPN N .-.. Lard Yu IlpptfcftlliRQN <br /> 1 pe Dtet Lae�el Dn Cetl. <br /> CONTRACTOR And 6 P / Y <br /> SERVICE REQUEST ORbat BILLING PARTY Cy / N <br /> RandD&1 M PHONE M1 (� r�)��,� <br /> MAILING ADDRESSD�LJ IJ 1�f J `[ `w FAX X ( ) <br /> CITY G-L«liCZ�f' STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned Amer, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/END 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, I, 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 ea <br /> it is available and at the same time it Is provided to me or my representative. ) �/ <br /> Nature of Service'Request: /`'i•//"YM'>/J'p� `��� `/y� /T l-'�/ Service Code <br /> Assigned toEmployee N O!/ _ Date <br /> Date Service Campleted _/ C//, Further Action Required: Y ! N PROGRAM ELEMENT 3, <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check M Recvd By <br /> n <br /> 023y 0 33v-= c -; y _� c <br /> RENS _/_/_ SUPV _/ /_ ACCT _/__/ UNIT CLK <br />