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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br />FACILITY ID # ' RECORD ID # J I r INVOICE #I [1 03q/ <br />rACILITY NAME <br />y t �1 �� BILLING PARTY <br />�'f�� ��iZL� <br />SITE ADDRESS <br />CITY �C�C �i�A/ CA ZIP <br />OWNE OPERATOI :_= 1 J U y A V BILLING PARTY Y / <br />DBA PHONE #1 (y�E* S3 <br />ADDRESS <br />PHONE #2 ( ) <br />CITY STATE ZIP <br />APN # F Land Use Application # <br />BOS Dist Location Code <br />CONTRACT nd/or _ <br />SERVICE REQUEST OR �CCTTSnL �yY'Y��ilc� ���Cu. SiV�� BILLING PARTY Y -yN <br />DBA 0 I r ( I I PHONE #1 ( ) -'16q- e J <br />MAILING ADDRESS f �.. �aC 76 FAX # ( OGi <br />CITY f4 STATE �' ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS/EHD 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 praparedithis application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY OrdinancelCode and tandards,"State and Federal laws. <br />APPLICANT'S SIGNATURE : <br />Title: Date: //— 2-4— 'l6 <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 />I C 15 d V d I l tl U L U OI KJ OL L— .. — I— a V. — i ......, w — — .." - -"- ..., <br />Nature of Service Request: Service Code ( °'I <br />Assigned to 1��� Employee # V Date <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # Recvd By <br />3 <br />00 <br />SUPV _/ / ACCT L/ /, i p UNIT CLK <br />_ice' <br />