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SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> k <br /> ACILITY ID # RECORD ID # O� INVOICE # D <br /> FACILITY NAME .4;gJTE DOE � Y°�JL%j BILLING PARTY © / N <br /> i <br /> SITE ADDRESS 15-773 e_,_ <br /> F CITY CA ZIP <br /> r <br /> OWNER/OPERATOR Sb E Vy E BILLING PARTY Y / N <br /> DBA PHONE #1 (ZU <br /> ADDRESS Iye 2" E' ��� T�€� )PD. PHONE #2 <br /> CITYSTATE C04 ZIP <br /> APN --- Land Use Application # <br /> �203_��v-07 4p� <br /> IF <br /> /7�5 y�—Z S Bos Dist Location Code <br /> r CONTRACTOR and/or ' <br /> 9FRV199 RFOUPSTOR rrOF o�r !✓UC �i,lG, BILLING PARTY Y / <br /> E <br /> DBA ~r PHONE #1 (Zo y } 767 - ?7o/ <br /> /J <br /> MAILING ADDRESS v �' yST �I FAX # ('LAr7 <br /> CITY LO STATE L� Zip 1 <br /> i BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHO 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> # JOAQUIN COUNTY Ordinance Codes a andards, State Federal laws. <br /> APPLICANT'S SIGNATURE ' <br /> l Title: Date: /2 /5 <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 /> i <br /> Nature of Service Request: , Service Code _ <br /> w <br /> Assigned to Employee # 21 1C, Date ? <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> f <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> i <br /> SUPV / / ACCT / V f� UNIT CLK <br /> t <br /> i <br />