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lGy1r `u/ X96 Su l �+�l cL L�+ Py320 -6v 74 / <br /> SERVICE REQUEST C.Cr1R —gH 00 61)�Revised 8/23/93 <br /> FACILITY ID # RECORD ID # 00 INVOICE # o 5, 1 ED <br /> FACILITY NAME �G"` 1`�� ��� �( �/` BILLING PARTY Y 1 <br /> / N <br /> SITE ADDRESS —^�_J�j�Il7 <br /> CITY CA ZIP <br /> OWNER/OPERATOR �� - ../" �M--���- BILLING PARTY Y / Q <br /> DBA �] PHONE #1 ( ) <br /> ADDRESS 7 S`( C —,-64e—� -Io � PHONE #2 ( ) <br /> CITY STATE ZIP <br /> P APN # P Land Use Application #I BOS Dist Location Code I f� <br /> 6 <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR -/46-z9"L � //- / <br /> BILLING PARTY Y / N <br /> I ^ <br /> E <br /> DBA PHONE #1 <br /> �� <br /> c <br /> MAILING ADDRESS /z/ Z C FAX <br /> CITY U/ STATL�X ZIP ( ZD CIZ— r <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHD 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. PAYMENT <br /> 1 also certify that I he pre($ai d a appli ati and tLttle r to be perf ed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinan a Codes Sta ar S to and Felaw . _ APR 2 3 1996 <br /> / SAN JOAC)U,I;COUn. <br /> APPLICANTS SIGNATOR 6 Pi <br /> 1 Z N,VIRONMENTAL HEIC <br /> ALTH DIVISION. <br /> Title: 4 Date- 11�= <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 /> environmental/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 /> Service CodeNature of Service Request: <br /> Assigned to \v(y � # Date <br /> Date Service Completed � <br /> Action Required: Y /� PROGRAM ELEMENT Z-- <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> -? to <br /> REHS _/_/_ SUPV _/_/_ ACCT / H UNIT CLK _/ /_ <br />