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SERVICE REQUEST - --- (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # 11 RECORD ID # S�V' INVOICE # <br /> ACILITY NAME �llUc- A",� BILLING PARTY Y / N <br /> SITE ADDRESS <br /> IrS-- �:A, ?s' w� <br /> CITY CA <br /> U! CA ZIP <br /> OWNER/OPERATOR Z-YJ� �Ee4t� BILLING PARTY <br /> DBA PHONE #1 (Colf )17-zq- <br /> ADDRESS ( C> 12� s/nWal m Zl ',1 PHONEE2#2 ( ) <br /> CITY /v1157�_F .Tb STATE ZIP �/ 5S -5�1- <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> and/or 1^,� T <br /> SERVICE REQUESTOR 1 v\11�GC_ Rdbe� BILLING PARTY <br /> pEIA Ae�-& LF7a PHONE #1 <br /> MAILING ADDRESS —. \ FAX # ( ) <br /> CITY /0 �N STATE c=4 -_ ZIP qg,?-6 I <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 are ication and that the work to be performed will be done in accerdance wftw Z11 SAN <br /> JOAQUIN COUNTY Ordinan Codes tandar s„ Stat Federal Laws. , ,--- � 'N <br /> APPLICANT'S SIGNATURE <br /> Title: �.o��CT //V�"' ' -`"� Dater g` ( 7 r `ANJOAOU'NCUUN Y <br /> BLIC HEALTH SERVICES <br /> ENVIRONMENTAL.HEALFH DIVISION <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 rep re entative. <br /> Nature of Service Request: -u s<./�5 Service Code C LT <br /> c <br /> Assigned to : Employee # Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid =Date of Payment Payment Type Receipt # Check # Recvd By <br /> - , �- o <br /> SUPV / / tL ACCT _/_/ UNIT CLK _/ /_ <br />