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SERVICE REQUEST v (EH 00 61) Revised 8/23/93 FACILITY 10 # Q /� RECORD ID # u ( 1 INVOICE # FACILITY NAME (✓AP FO JT /rl 9/R/�t/�(�./y BILLING PARTY Y l SITE ADDRESS (�2 3 G • I Li�rr—O CITY 2i Pot CA ZIP OWNER/OPERATOR )3)?5dT 4'3AR7-O BILLING PARTY Y / G� DBA G. / PHONE #1 ( ) ADDRESS 766 -3 AlL - m t L y E0 g PHONE #2 1— PO ) - CITY (�� C�QSTATE � ZIP 15 pAPN # �La�e Application #/a / I S 9 3 BOS Dist I Location Code CONTRACTOR and/or SERVICE REQUESTOR G.L- BILLING PARTY / pN DBA )V AJ GF ELLS Er PHONE #1 ( ) 7- MAILING ADDRESS l�/ /`� Gam—"-ln Er/eAL� ,l FAX At ( ) CITY /YIO(7,5 / C/ STATE 0/s ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/END 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. ala,�`�Mlj�- I also certify that 1 have prepared this application a hat the work to be performed will be dorR•�nrl.ece6rihinoe with all SAN JOAQUIN COUNTY Ordinance Codes end a ards, Sta a deral laws. APPLICANT'S SIGNATURE : JUL 3 0 1996 pU �GAgUlNC6'uWV7� . Title: Date: b EA AL HEA(�VI CES AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or eQ�.4v` seme, 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 . �-- Assigned to a 1C__Y ^o P Loyee # D21 Date -7_/��/ Date Service Completed / / Further Action Required: Y / i PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS ( /�_/ SUPV _/ / ACCT _/ / UNIT CLK _/ /_