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SERVICE REQUEST ` -CSERVitUOReiv -813/93 <br /> FACILITY ID # I RECORD ID # 3NVOICE <br /> FACILITY NAME (E#Q('7[� "" � BILLING PARTY <br /> SITE ADDRESS <br /> CITY t CA ZIP J <br /> OWNER/OPERATOR ot i ILLING PARTY Y / N <br /> DBA � , E #1 <br /> ADDRESS <br /> tl� � E #2 3 <br /> _ <br /> CITY <br /> APN # Land <br /> t Location Code <br /> F 1E <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR _C`7 V � y 1ILLING PARTY Y / ?I <br /> DBA 0 iE #1 ? �M- <br /> MAILING ADDRE55b rn �4 S4 J( # ( 1��� �3 L <br /> CITY W3eP fo STATE " ZIP �S ✓ � <br /> BILLING ACKN0WLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> DHS/EMD hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this an and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Cod and Standards, State and Federal laws, <br /> APPLICANT'SSIGNATURE <br /> Ti t l e• 'r.'t t/1G tv` S.-u� L'•t.+�l +Pi1 Date: -- <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: } r� Service Code 0 <br /> Assigned to C -r- L Employee Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By: <br /> 7r <br /> RENS / / <br /> SUPV .^/� ACCT UNIT CLK �1 ' <br />