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SERVICE REQUEST \ (EH 00 61) Revised 8/23/93 FACILITY ID # - RECORD ID # INVOICE # FACILITY NAME T2a1 �/ Tb RE/11 7--A BILLING PARTY Y / SITE ADDRESS /1lLGG t'r w �Iyf7� fr r��LA��s� /-Z/-2- CITY � �GY CA ZIP OWNER/OPERATOR I �L�M I T BILLING PARTY Y / DBA T/�F�.V N ! Q L�S PHONE #1 ADDRESS FAST Bj20K k) R=4-22 • PHONE 02 ( ) CITY .5Ar4 .I aS STATE ZIP APN # Land Use Application # / 7.9 6) - S ^ -7 BOS Dist Location Code CONTRACTOR and/or SERVICE REQUESTOR T v/v � / / BILLING PARTY (,z) / N DBA ( 9 h L/T{/ LD�OL /NSpccT/o�/, /,✓C, PHONE #1 Mi MAILING ADDRESS /2 x/ /Z 4-z FAX # ( ) CITY / 0 f TU STATE C.A _ ZIP J` r11-f BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD 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. *,AYmtr1T RECEIVE[ 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes a andards, S e aril Federal laws. A P R Q 11991 APPLICANT'S SIGNATURE %JUAUUINCOUNTV HEALTH J` P Date: :NVIRONMENTAL HEALETR VICES Title• H DIVISION ' � •�l' S 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 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 1 , \ , _ Employee # � L Date / Required: C / / —7 FurR uired: Y / N PROGRAM ELEMENT d Date Service Completed S / / �1 Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By SUPV _/ / ACCT �/ . 7 [U UNIT CLK _/ /