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i SERVICE REQUEST RVRE07�pPTgl$-aJZSJ9S' FACILITY ID _ INVOICE # FACILITY NAME -fl2vq G L L 1 L /V - BILLING PARTY Y N SITE ADDRESS CST A4) L.C10Z ilvv IT CITY / /Ntli 7 CA ZIP % S 3 7zl OWNER/OPERATOR f/,. � %, J-, 8ILLING PARTY �N DBA 7" ! I PHONE 41 f ADDRESS SZ C) ,i C y' /�L(/(� PHONE #2 ( ) CITY T/CH� �/ STATE ZIP �APN d Land Use Application # BOS Dist location Code CONTRACTOR and/or SERVICE REQUESTORyVRA1y�l9',/,f/T f=�nU.LQDNM c�a/ATi9,L�//SEk UICcS .-{-j17�, BILLING PARTY Y / DBA //'Tf T'U/�/ 19A U/�G - /�E�"(,I./I-- PHONE #1 /� ;MAILING ADDRESS �76� Ac/- (/1LW W,er� FAX # ( )032 - S-IS4< CITY �,c.rY/_l/ STATE Cl 21P C1f-Z 7� 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN �QL JOAQUIN COUNTY Ordinance Codes Standards, ate and Federal laws. 2� �t l.' APPLICANT'S SIGNATURE d(/ Title: i CSL Date: 0 Z I Z1— AUTHORIZATION AUTHORIZATION TO RELEASEE 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 environmenta L/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. na Nature of Service Request: A,C� US LC -� �'ALoixS Service Code Assigned to 5tAye 1//(A Employee # oji�y Date _/_! Date Service Completed _/_f Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By RENS i _/_/_ SUPV _/ %_ ACCT t � / ��. p UNIT CLK