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SERVICE REQUEST ) // (SERVREEO43 Q) Revised 5/13/ FACILITY ID # ('� 1 q� RECORD ID # a ( 7516, J FACILITY NAME �-�Ct -FAC # �_.T_ SITE ADDRESS O Ce v V # L�`� ?J CITY � �/ G ZIP OWNER/OPERATOR BILLING PARTY DBA /ea z,� v Y / N PHONE 01 ADDRESS �/ C 3/z� S -�' PHONE Q ( ) e z c&� CITY STATE ZIP '7 APN # Census --------- BOS Dist Location Code City Code ------ CONTRACTOR and/ SERVICE REDl1ESTOR ✓ Y� Il YlJ T_//��Q��-K�t�Wl�l i-C-- `" BILLING PARTY Y N DBA G, PHONE #1 ( �' ) - Z _ MAILING ADDRESS �l/ 'J FAX # < ) j CITY W J �'C l 1 J STATECP 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 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, 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 providedtome or my representative. Nature of Service Request: L).5,,ce t L 6& Service Code Assigned to Employee # Date Date Service Completed _/ / Further Action Required: T / N PROGRAM EL ENT �� Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By SUPV• _/_/__ ACCT _/ I UNIT CLK _/_/_