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01/08/97 15:06 HO. —255 1)0_ SERVICE REQUEST CEN 00 61) Revised 8/23/93 "1=:j7 FACILITY ID p RECORD IO p INVOICE p 5y FACILITY NAME P Q-C bcn BILLING PARTY Y / SITE ADDRESS W L CITY CA ZIP_ak!l 2A BILLING PARTY Y / OIINER/OPERATOR PHONE 01 DBA PHONE 02 ADDRESS CITY �` `1(�\ STATE \ ZIP -- APN p Land Use Application M Location Code BOS Di at CONTRACTOR and/or BILLING PARTY Y / N SERVICE REQUESTOR PHONE pi OBA FAX p (�� ) y�• Z MAILING ADDRESS _• �� a\o �- e CITY �� >1•S 1 STATE r-� ZIP rator or agent of same, acknowledge that all site and/or project specific BILLING ACKNOWLEDGEMENT: I, the undersigned owner, ope ivity sift be billed to the party identified as the BILLING PARTY an pHS/EHO hourly charges associated with this facility or act Paye i of this form. 1 also certify that I have prepared this application and that the work to be performed wilt be done in accordance with atl SAN JOAQIIIN COUNTY Ordi Fa dard ie and Federal ws— APPLICANT'S SIGNATURE; Date: Title: L V � C —� 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 RONMresuNTA yHEALTH DTVI data or environmental/site assessment infonwation to SAN JOAQUIN COUNTY PUB it ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or mN p i Service Code Nature of Service Request: u,L Date Assigned to r ( C! �T S EmploYee feted / / Further Action Required: Y / N PROGRAM ELEMENr Date Service Comp T Receipt 0 Check 1t Recvd BY Fee Amount en Amount Paid Date of Payment Paymt YPe / / ACCT �/ / UNIT SUPV --