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SERVICE REQUEST (SERVREO) Revised 5/11/o FACILITY ID # Amount Paid RECORD ID # Payment Type BILLING PARTY Y = FACILITY NAME SITE ADDRESS CITY ,/ , CUL � /0 i1 �Ivv r, OWNER/OPERATOR _�- 91 60.T Q a j a 41 /) \-i Q - DBA ADDRESS CITY APN # PHONE #1 ( ) PHONE #2 ( ) STATE ZIP Census -------•- BOB Dist Location Code City Code -----• CONTRACTOR and/or SERVICE REDUESTOR W `S �P i� �/( y� / (�. / P V s DBA MAILING ADDRESS 2 BILLING PARTY T/'/ N PHONE #1 FAX # C Off ) ' 9 0 CITY S�%(, k lo li STATE \�� ZIP BILLING ACKNOWLEDGEMENT: I, 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. I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Title: 0 UJ Gj P V^ Date: % (/,) — � -3 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: /./ '- Assigned to Date Service Completed _/ / Employee # Further Action Required: Y / N Service Code Date _/ / PROGRAM ELEMENT %001 Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS I _/_/_ I SUPV I _/_/_ I ACCT I _/_/_ I UNIT CLK I _/_/_