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SERVICE REQUEST —' (SERVREO) Revised 5/13/93 <br />FACILITY ID # <br />p6 40 <br />RECORD ID # <br />Y ' 3 �S/ G <br />BILLING PARTY <br />Y / <br />FACILITY NAME C L,V e- aso-)-1 PA -2 <br />SITE ADDRESS �` wJLBe- t) �G+ # 7607 <br />CITY 54yc—CT(Ti - tv zip 9s2z> AC # <br />OWNER/OPERATOR ` <br />BILLING DARTY <br />APN # <br />DBA <br />PHONE #1 ( ) <br />ADDRESS 1 0`5 /U • 6-t, Dormido ✓�-f PHONE #2 ( ) <br />CITY �2-1 l6n STATE e,4 ZIP % S Z4 Z <br />Census --------- I BOS Dist Location Code City Code ------ <br />CONTRACTOR and/or <br />SERVICE REOUESTOR / `� �'e 15 I CC igBILLING PARTY l�Y�% / N <br />DBA PHONE #1 ( -1/4) <br />MAILING ADDRESS /d. 'Z- -3 co s E L i>/Z.a D FAX # ( ) <br />CITY L/416-6 Fdle S -Il- STATE (2'4 ZIP %a%.36'' <br />BILLING ACKNOWLEDGEMENT: 1, 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 accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. <br />APPLICANT'S SIGNATURE <br />Title <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 as <br />it is available and at the same time it is provided to me or my representative. <br />Nature of Service Request: <br />%9.4tii ///OLt'� <br />Assigned to Employee # [/ � <br />Date Service Completed _/ / Further Action Required: Y / N <br />Data <br />Service Code -I <br />PROGRAM ELEMENT a3• Cf& <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />REHS _/_/ SUPV _/_/ ACCT _/_ UNIT CLK _/_/ <br />