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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # (( RECORD ID # �1q;.� �/ INVOICE # <br /> FACILITY NAME .1l b"k:T 4-IW IIJ i�.S L'�UF'.G-b-� JOk•� - z � 1 BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY T��a CA ZIP q 53 7 ✓y <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> IAPN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR Wim`- G(Nn/`�"'r BILLING PARTY ' ' // N <br /> c� <br /> DBA PHONE #1 C L ) 2 I- .� <br /> MAILING ADDRESS FA% # ( ) <br /> i <br /> CITY STATE C-A ZIP S (--4-G <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/END 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 also certify that I have prepared this application and that the work to be performed will be done in accordandb with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE �� �ltr� 0y �V\ IL O-L� 4 <br /> a 1 <br /> Title: !^��L�-��rc'o I�-�'K� Date: & <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 /> Nature of Serv(i�ceRequest: f/13�7(�j2q {ti�GU_v\� ,(>�/S \^ Service Code �2. 2 <br /> Assigned to ���h�.�'a Nom, I Employee # U4 Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> °1 <br /> REHS - _/ / SUPV /_/ ACCT _/ / UNIT CLK _/ /_ <br />