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01-17-1946 09:33AM FROM TO 15108958426 P.02 <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/43 <br /> FACILITT ID 0 �� 1) -7 RECORD ID # a I� INVOICE it <br /> FACILITY NAME �7cj BILLING PARTY Y / p <br /> I <br /> SITE ADDRESS <br /> CITY I `'7�p CCA ZIP <br /> I <br /> I <br /> OWNER/OPERATOR LO —V(" 6 Lt� BILLING PARTY Y / <br /> DBA I'Tn'��j PHONE #1 (1 <br /> T <br /> ADDRESS r 1c�� C / PHONE #2 <br /> CITY STATE <br /> ,�JJI \ CA- ZIP Cly�D D3 ' <br /> �,LJ� ��,\�L\ <br /> APN # Land Use Application # <br /> 80S Dist Location Code <br /> CONTRACTOR and/or 1 <br /> SERVICE REQUESTOR Cb C v\1\ VG' BILLING PARTY (JY / N <br /> I <br /> DBA h PHONE #1 ( 5C6 ) S X33 <br /> MAILING ADDRESS I\�\ \ �yo��� \f 1 •� FAX R gyri—( <br /> CITY V�G�t�1 C�� STATE C ZIP <br /> M c I <br /> i <br /> BILLING ACKNOWLEDGEMENTS I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/ENO hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> i <br /> I also certify that I hleve pr ed this application and that the work to be performed will be done in accordan`� i �U ��B�F1 <br /> JOAQUIN COUNTY Ordinance C ar lsrSt rat laws. <br /> 5 ��tt <br /> a�,d "tet-�e RFrEIVE ' <br /> 1 � _ <br /> APPLICANT'S SIGNATURE r� �1Nov <br /> Title: 1 \"Y U\� \ '� i Date., ✓\ \` \0.� SAN'JUAUUIN CUUNTY <br /> PUDUC HEALTH SERVICES <br /> ENVIR0NyE;JJAI l rALTI�pNISIC)N <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agen r 0 , o <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical date and/or <br /> environmental/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DiVISIOk as soon as <br /> It is available and at the same tlme it is provided to me or my representative. <br /> Nature of Service R-17"st: / Service Code <br /> Assigned to ✓ ' A+ — Employee it C/'�� Date <br /> Date Service Compteted / / Further Action Regvired: Y / NPR DGRAM ELEMENT <br /> I <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> I <br /> I <br /> I <br /> [R-E <br /> S _/ 7/1- SUPV ACCT _/ / UNIT CLK <br /> I <br />