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I SERVICE REQUEST (SERVREQ) Revlsed 8/23/93 FACILITY ID N '`I RECORD 10 N / INVOICE N fAf.ILIiY NAME \ /r �-+C.V IC�CJ)�YI try BILLING PARTY Y // N SITE ADDRESS WA _lis C I TY D q3qD t�— OWNFR/OPERATOR ��--�C� ( �V BILLING PARTY Y / N DBA � �/ / PHONE 01 ( 5 Id )_ fes- _ ADDRESS 1 y �Dr U/y �-/ PHONE (�N22( ) CITY ��r-, �LL`>•C.�-`�-'�- STATE �" ZIP � 1APN N —p Land Use Appltcati on N I8 O Dist Location Code CONTRACTOR and/or ^ �,\\ SFRVICE REGUESTOR ` J�CIV - ISI VLJLF-IOI�1 BILLING PARTY ,L�/I Y / Nr' ORA �) /— r, I,, ,� n PHONE 01 ("J/0 )T Y7- Z.4 d" MAILING ADDRESS E\\Cfp; ( l !C �-�L' �L�^ �,�. �� (F/AX(N� CITY �Iye-t�h- A—o — STATE� ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site end/or project specific PNS/END 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 red this application and that the work to be performed will be done In accordance with alt SAN JOAQUIN COUNTY 0 mance Codes a Standards, State and Federal laws. APPLICANT'S SIGNATURE Title: Date I — 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, Beotechnfcal data and/or environmental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available end at the same time it is provided to me or my representative. Nature of Service Request: N of O Service Code (, y Assigned to Employee N Dstel15 /�/ Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By ad RE MS _/ /_ SUPV _/_/ gCCT J / J`7 / [ T UNIT CLK _/ /