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SERVICE REQUEST (SERVREQ) Revised S) FACILITY III # RECORD ID # BILLING PARTY Y / N FACILITY NAME SITE ADDRESS SCOLL CITY S7(JC�T'�'7 CA ZIP- 'L- OWNER/OPERATOR IP OWNER/OPERATOR ll;e z /��/Yl�� BILLING PARTY 7 / N Cti/f / c[ �i �f� 4 �CCf/i�I'7CNt a nc 1 PHONE 01 co 7- ) � `�G- 3C-6 L-/, PHONE 92 ( ) ADDRESS C11 G`--=y��"/� G - STATE ZIP 2 0 y 7 z NOS=DistAPN # Census __...__.. NOS Dist Location Code City Code ...... CONTRACTOR and/or BILLING PART? T / N SERVICE REOUESTOR DBA PHONE #1 ( ) MAILING ADDRESS FAX # ( ) 1 CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the urdersigned owner, operator or agent of same, acknowledge that all site and/or project specific PNS/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 I 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: 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 IL is provided to me or my representative. Nature of Service Request: Service Code Assigned to Employee # _ Date -/-/- Date / /Date Service Completed / / Further Action Required: 7 / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By to �- ;? -45 /(L -3607--3Oo7-35�3 30 RENS I _/_/-I SUP _/_/ ACCT I _/_ _ I UNIT CLK