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SERVICE REQUEST , / (EH 00 61) Revised 8/23/93 <br />FACILITY ID # RECORD ID #�l INVOICE # <br />FACILITY NAME <br />SITE ADDRESS <br />eA C- (_ <br />CITY _ k R�L, 3kti ) CA ZIP, <br />BILLING PARTY Y / N <br />i <br />lei 2 <br />OWNER/OPERATOR /�, ��(;,, /tj 7' ,y1� ,, �� BILLING PARTY Y / N <br />DBA ( tL : ✓� l/ �'�'ll-� , C��/�-C-) PHONE #1 ) <br />ADDRESS ��� J S ('If ____a&L---J'_' "2(, lL� 61—ja4 <br />CONTRACTOR and/or <br />CFRVIrF RFOIIFSTnR <br />DBA <br />MAILING ADDRESS <br />PHONE #2 (—)-- <br />I <br />BOS Dist Location Code <br />BILLING PARTY Y /('IN <br />PHONE #1 ( 7) 2- <br />FAX # d/,n�T.� l &j! d.7W 7 <br />CITY/fY/ .10.<iLwL J STATE(_42I2I5( <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site arid/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 />I also certify that 1 have prepared this application and that the work to be performed will be done in arAal""'I l SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal/tail RECEIVED <br />s <br />APPLICANT'S SIGNATURE <br />SAN JG. .. U Ii`J -•e i•� <br />Title: C T O Date:�� ,,5 PARI IC HEAIJ;a <br />CNVIRONMENTALiic:L(; Ui'vS;:M <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 time it is provided to me or my representative. <br />Nature of Service Request: <br />Assigned to <br />Date Service Completed / / <br />Employee # <br />Further Action Required: Y / N <br />Service Code 0 _� LI <br />Date /Z� / 0 / / I <br />PROGRAM ELEMENT -2zC2V <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />REHS I _//_ I SUPV I _// I ACCT '-] /,' _/ I / I UNIT CLK I _ _// <br />