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J SERVICE REQUEST (EH 00 61) Revised 8/23/93 FACILITY ID # O / RECORD ID # INVOICE # D FACILITY NAME 199 Z& BILLING PARTY Y SITE ADDRESS i3q q A-)1 YW 1 N STS p CITY A'NT15: 4 CA ZIP 9s OWNER/OPERATOR -S 07WLffi(J D CO//e/�- BILLING PARTY -Y / QT DBA It/ PHONE #1 (,;2-1 ) Ss ADDRESS02,7// .V/ �!�-skL-GG S7`. PHONE #2 (�/D ) �4,3 -,-2Z CITY STATE TX zip APN # Land Use Application #IF B Dist Location Code CONTRACTOR and/or SERVICE REQUESTOR BILLING PARTY / N DBA SA IYI E. PHONE #1 (1Y)3240 OeZ-2,r MAILING ADDRESS /�2�� lr-L�.y�Ef R� �90� FAX # ( ) CITY STATE G,15P ZIP � J BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, 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. 1 also certify that 1 have prepared this application and that the work to be performed will be done in4ccordance'with all SAN JOAQUIN COUNTY Ordinance Codes �and Standards, State and Federal laws. APPLICANT'S SIGNATURE : /) G . - AUG 2 1 1998 Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of some, 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 Service Request: ' Service Code 3qt- Fee Assigned to � q '`[A' 1Employee # J l� Date —1— Date Service Completed / / Further Action Required: Y / N F�EMENT Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By RENS / /� SUPV _/ / ACCT / /_ UNIT CLK _/ /