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SERVICE REQUEST R 7^1 R ised 8/23/93 FACILITY 10 * RECORD ID # INVOICE # CA FACILITY NAME WAYNE C . CASTLE BILLING PARTY / -A SITE ADDRESS 6106 X FRENCH CAMP RD CITY MANTECA CA zip 95336 OWNER/OPERATOR SAME AS ABOVE BILLING PARTY Y / N DBA PHONE #1 ( 209 ) 982_- 1 641 ADDRESS PHONE #2 ( ) CITY STATE ZIP --ArN # p Land Use Application # IBOS Dist Location Code CONTRACTOR and/or SERVICE REOUESTOR WON!_ -f FPN TUTEER4; TN(� BILLING PARTY DBA � PHONE #1 ( 2no ) i7G -0()11___ MAILING ADDRESS 4578 FEATHER RIVER DR. , SUITE A FAX CITY STOCKTON STATE CA— ZIP o591Q 8111ING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific CNS/FWD 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 l Federal laws. APPLICANT'S SIGNATURE /_4C i VV ��M� +n ,{ IF 4f Title: CNII. �V�� Date: Il1V'fl ILI 1CPA- 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 results, geotechnical data and/or envirormental/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: 40Ti CTTTTA TTS WIT REPORT Service Code -i Assignod to 1 CoLE1 FIS Employee # "? Date —/—/ Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By RFHS _/ / SUPV _/ / ACCT S/ / / '7 UNIT CLK _/_/_