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1� SERVICE REQUEST <br />(EH 00 61) Revised 8/23/93 <br />FACILITY ID # <br />Amount Paid <br />RECORD ID #� <br />IWWN VVV 31 <br />Receipt # <br />INVOICE <br />Recvd By <br />a3L4 <br />a� - <br />-? 14A (D <br />� <br />FACILITY NAMEI--. O II `� J Ll a � S w2ILLING PARTY Y / N <br />SITE ADDRESS(/e(/J —�yI '/ - 1'�' ` �'�y Y w <br />CITY AUL 5141J—V1 '\_ CA ZIP <br />OWNER/OPERATORGmd yLI V U t/ uc " BILLING PARTY Y / 9N <br />DBA n / PHONE #1 ( ) <br />ADDRESS �J Iyy'y •�� r Por P�HONNE #2 ( ) <br />CITY 31 1�C A✓1 11 P l STATE C4 ZIP <br />APN # P Land Use Application # <br />IBOS Dist Location Code <br />r <br />CONTRACTOR and/or �n <br />SERVICE REQUESTOR Y Il�� ( Y I`�V BILLING PARTY Y N <br />Y I 11 V I <br />DBA <br />T PHONE #1 (hLo)3-k�' - <br />MAILING ADDRESS I n375 I I/y��/�' ' '� )W/� jtt )� // (any r/�'r 1 �7 FAX # ( ) <br />CITY V �/ ,'S nbl "- W C/V 1 I V STATE vP ' ZIP "I—CJ 01 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, 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 />I also certify that I have prepared this application and that the work to be performed will be done in pro <br />"@Ce -with ell SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. - <br />PLICANT'S SIGNATURE IIW 1) <br />it le• 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 time it is provided to me or my representative. <br />Nature of Service Request: 1 vV0E— U 03 Lkr tf Service Code <br />Assigned to L):2 ' 1 WJ I C>� Employee # C1 C� yJ Date L/ 77 <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />a3L4 <br />a� - <br />-? 14A (D <br />SUPV I / I ACCT I _// I UNIT CLK I _/_J_ <br />