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SERVICE REQUEST .,., (EN 00 61) Revised 8/23/93 FACILITY NAME SITE ADDRESS CITY OWNER/OPERATOR DBA ADDRESS CITY F=APN # _ STATE ZIP Land Use Application # CONTRACTOR SERVICE REQUESTOR DBA MAILING ADDRESS CITY C( Z(7 0 BILLING PARTY Y / N BILLING PARTY I Y / N PHONE #I ( ) PHONE #2 ( ) BOS Dist Location Code BILLING PARTY ` Y/-?,f- FAX f N PHONE #I (%�) l 3�- () /s FAX # (C�) � - S CZ - STATE Com, ZIP -(/ BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site arid/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 t of this form. P��A//Y��M,,`E,,NTnn I also certify that 1 have prepared this application and that the work to be performed will be done in accoR��=M1VA9QAN JOAQUIN COUNTY Ordinance Code and Standards, State and Federal Laws. D E C 13 19x5 I 1 A OLW .. 11 I1:.: ft:.,,MTV APPLICANT'S SIGNATURE ' a 71� `�lz(l S ENVIfimWi:m AEHoA4fHDIV151 Title: / '�V )/�� " Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 (,�'}V, ^Seer/vice Request: Service Code Assigned tp� I Employee # Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amoou,}-n-t Amount PaidDate of Payment Payment Type Receipt # Cheyc/k FACILITY ID # �� I l RECORD ID #/ 1 l/ INVOICE # FACILITY NAME SITE ADDRESS CITY OWNER/OPERATOR DBA ADDRESS CITY F=APN # _ STATE ZIP Land Use Application # CONTRACTOR SERVICE REQUESTOR DBA MAILING ADDRESS CITY C( Z(7 0 BILLING PARTY Y / N BILLING PARTY I Y / N PHONE #I ( ) PHONE #2 ( ) BOS Dist Location Code BILLING PARTY ` Y/-?,f- FAX f N PHONE #I (%�) l 3�- () /s FAX # (C�) � - S CZ - STATE Com, ZIP -(/ BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site arid/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 t of this form. P��A//Y��M,,`E,,NTnn I also certify that 1 have prepared this application and that the work to be performed will be done in accoR��=M1VA9QAN JOAQUIN COUNTY Ordinance Code and Standards, State and Federal Laws. D E C 13 19x5 I 1 A OLW .. 11 I1:.: ft:.,,MTV APPLICANT'S SIGNATURE ' a 71� `�lz(l S ENVIfimWi:m AEHoA4fHDIV151 Title: / '�V )/�� " Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 (,�'}V, ^Seer/vice Request: Service Code Assigned tp� I Employee # Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amoou,}-n-t Amount PaidDate of Payment Payment Type Receipt # Cheyc/k Recvd By �� I l ✓ -" U /V#/ I l (l RENS _// SUPV _/_/ ACCT'- >' // _�—,_.. UNIT CLK _/_J_