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• v <br /> SERVICE REQUEST (SFRVREG) Revised 8/23/93 <br /> FACILITY ID R "'RECOPD ID N bo INVOICE N <br /> rACILItY NAME ) 1=-1-� 511(G ��7CN7 BILLING PARTY / N <br /> SITE ADDRESS II �� /C ` //--�� <br /> CITY�b N CA zip 7.�aO C. <br /> rAIHE /OPERAT --O'r �.t�E-2 BILLING PARTY N <br /> DBA PHONE N1 C:a-ea)�603- 7V16 <br /> ADDRESS PHONE N2 ( ) <br /> CITY STATE ZIP <br /> --APR N Lard Use Application N <br /> BOS Dist Location Code <br /> CONTRACT and/or <br /> SERVICE REGUESTOR //� -- //�� BILLING PARTY Y / N <br /> DBA J(�OCkTOLI S-EIZ !/ F OiIJ _C..Ya. PHONE M1 (ZG' ) - ">-,•-S <br /> MAILING ADDRESS O'�n- ocr ,r FAX N ( 2-&F- 6f-�- Eje <br /> _ <br /> CITY�N STATE �_ ZIP <br /> �- BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that sit site and/or project specific <br /> PHS/EHO 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. •pAYoWL� y7-,, <br /> I also certify that I hVerLticatIonn and that the work to be performed wllRENMy LIVFFlecordanea with all SAN <br /> JOAQUIN COUNTY Ordinancte Federal <br /> tows. MAY 2 0 1996 <br /> IAN <br /> APPLICANT'S SIGNATURE �'/ C�/i(l�J1111:(�Uiy Tt <br /> ENTAL HEAL rH p V Slnti <br /> Title: �Llss Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or pent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data ardor <br /> envirormentst/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: Service Code / <br /> Assigned to T)H 0 \-J 19 Employee N q, Q.'D---5 Date / L /_ to <br /> Date Service Completed _1_/_ Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amc nt Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> aL <br /> C' // � <br /> RENS /_ SUPV _/ /_ ACCT _/ / UNIT CLK _/ /_ <br />