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�Ar SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID N RECORD ID M t) INVOICE N <br /> FACILITY NAME BILLING�fQ.( „� BILLING PARTY Y' / N <br /> � <br /> SITE ADDRESS 2-7/4q __S PI1 <br /> 5fn <br /> �/ CITY c _J_oo �(I[/ CA ZIP��P <br /> / WNER✓OPERATOR <br /> DBA ���/7]I��( I 1 ter <br /> � \ '` L11 <br /> �T L` e / <br /> Ir /��� PHONE M7 <br /> {"t <br /> ADDRESS N�lJ il) r\' �i� /1 �y`� PHONE N2 ( ) <br /> CITY f'-7 _-_ STATE CV"--Ai ZIP (00 <br /> ( �l —C) <br /> FppN p p Lard Use Applicet ion N — - <br /> IBOS Dist Location Code <br /> CONTRACTOR nrd/or <br /> SERVICE REOUESTOR BILLING PARTY <br /> DBA PHONE N1 ( ) <br /> MAILING ADDRESS FAX R ( ) <br /> CITY STATE ZIP <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 /> PAYMENT � - <br /> APPLICANT'S SIGNATURE hF� �Yf�B <br /> title: Date: f111C O 1Q97 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the ownerSA J'AWi1N�V,g'�06yW.1yt�of same, of <br /> the property located at the above site address hereby authorize the release of any and all reBUWP. �i�A17Fi I5r end/or <br /> INVIROOk AL <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 <br /> l <br /> time It is provided to me or my representative. <br /> Nature of Service Request: l kV`p— In ��' ((/ Service Code <br /> Assigned to 4�rlse,�[at, Employee q cq Date <br /> Date Service Completed _/—I— Further Action Required: Y / N PROGRAM ELEMENT Z 30 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt A Check H Recvd By <br /> IA-74 — ss/aq� lice <br /> \ <br /> RENS _ �/ � � SIIPV�"'( <br /> �l 1 r <br />