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SERVICE REQUEST ^ ll j S Revised 5/13/93 #FACILITY ID # RECORD ID # ✓ PARTY Y / N FACILITY NAME I SITE ADDRESS QS�p S- 1400 ay, 'Road CITY FVFY?C./ �A;21fJ CA ZIP OWNER/OPERATOR Moil-�f I l.E� BILLING PARTY Y / H DBA PHONE #1 ( zmy )—Da, [4-15 ADDRESS '(�dL� /? • fg/A� �1✓� '"' "` /,I qPHONE #2 ( ) CITY -�Y�-v!e l-C(N�I�+ STATE CST ZIP OS'Z7 1 APN # Census --------- BOS Dist Location Code City Code --•-- CONTRACTOR and/or SERVICE REQUESTOR 7En�`C'd BILLING PARTY Y / DBA PHONE #1 ( U)l ) 514 MAILING ADDRESS AI Z� "1 S 11�� &t' FAX # CITY M�C��' 7�� STATE �`T ZIP 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. I also certify that I have prepared this application and that the work to be performed will be time in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standard[/ss,,, State and Federal laws. APPLICANT'S SIGNATURE :��f�L.— / Title: h�!✓C47CLS4441l E��C`JC\ Date: / 1zi /YA 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 of Sgrvice Request: Service Code Assigned to mployee # 0 ' 4- 7--� Date Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT a3 . c� Fee Amount Amount Paid Date of Payment Payment Type Receipt # Chec Recvd By REHS _/_/ SUPV _/_/ ACCT _/_ UNIT CLK