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SERVICE REQUEST (SERVRED) Revised 8/23/93 FACILITY ID # RECORD ID # iNVOICE # FACILITY NAME RARMOHAN SORI BILLING PARTY Y d N SITE ADDRESS 2OA1 F._ METTLER ROAD CITY T.OnT CA zip 95240 OWNER/OPERATOR FTARMORAN SORT BILLING PARTY Yf N DBA SUPER S MOTEL SAN LUIS OBISPO PHONE #1 L D ADDRESS 1951 MONTF.RF.P STRF.FT PHONE #2 C D CITY SAN T.TTTS ORTSPO STATE ZIP 93401 P APR # Land Use Application # ISOS Dist Location Code CONTRACTOR and/or SERVICE REDUESTOR WONG R.Nf:TNF.FRS F TV(' - BILLING PARTY Y { N DBA PHONE 41 i ) MAILING ADDRESS 4!K7A FFATTTF.R RTVF.R nR _ STTTTF.A FAX # t ) CITY STOCKTON STATE CA_ ZIP AS 21 9 BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/ERD 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 CCUNTY Ordinance Codes and Standards, ,State eraL Laws. APPLICANT'S SIGNATURE h!/ •`^^' '�.�- 4 Title: r.TVTT. F.Va TNRFR Date: 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 /oto me or my representative. Nature of Service Request: (.I V'J- C Service Code Assigned to G Employee # '--li;;L—` Date I/ Date Service Completed /C�/1 / / Further Action Required: Y M PROGRAM ELEMENT —11.0 d–d� Fee Amount Amount Paid Date of Payment Payment Type Receipt # I Check # Rscvd By REHS n--ZLL/-L9 / f� Sl1PV _/_' ACCT _J�_ UNIT CLK i _/�_