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SERVICE REQUEST V E ed 8 FACILITY ID # ` ` RECORD ID # S FACILITY NAME /�7/- ,) Ile I—y Z J/ � BILLING PART _ N \ JV SITE ADDRESSfI �' IA-7 q CITY ��u C y CA ZIP / -5S,Q CLJa/S 1 I k)U, 74i�;7 Lvst. 5k a)ajs a --jp"N V. 741 L OWNER/OPERATOR BILLING PARTY Y / M DBA PHONE #1 ( ) ADDRESS PHONE #Z ( ) CITY STATE ZIP EAPN # p Land Use Application # II BOS Dist Location Code CONTRACTOR and/or SERVICE REDUESTOR `C / ( 6 O P ei -4. BILLING PARTY Y ( M DBA ✓6N f�-cG //��M. p✓Y%R/llf/dl t!-1� L/DO —�1 LIZ pip PHONE #1 ( 9 S ) �4 cye qJ� " C s !T!/ Nd8�o 61r •rS FAX MAILING ADDRESS ( J1J e CITY NT.�� aS STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance CodesandStandards, State and Federal laws. APPLICANT'S,SIGNATURE` Title: /"ry C- c 2 g Y �n Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: _(A.rR f"eJ'IC fJ�.� I(4t i ID Service Code Assigned to B ; Employee # t ) T ' Date Date Service Completed / / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By s8 ail REHS _/ / SUPV / / ACCT _/ / UNIT CLK _/�_