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SERVICE REQUEST # D / a) Revised 5/1 /43 <br /> P <br /> FAITY ID # <br /> RECORD ID # Fi y Y <br /> CIL / N <br /> FACILITY NAME 144" <br /> SITE ADDRESS ] <br /> CITY CA ZIP <br /> OWNER/OPERATOR <br /> BILLING PARTY T N <br /> )/ <br /> DRA <br /> PHONE #1 ( ) <br /> C <br /> ADDRESS / / PHONE 42 ( > <br /> CITY STATE ZIP <br /> Census SOS Dist Location Code City Code ----•• <br /> APN # -..__-... <br /> CONTRACTOR and/or <br /> BILLING PARTY Y / N <br /> SERVICE RfQUESiOR <br /> DBA PHONE #1 _..-- <br /> HAILING ADDRESS FAX <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknwledge that al( 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 prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Code tandards, State and F ral laws. <br /> APPLICANT'S SIGNATURE � (� cn' <br /> Title: Y�-�Y�-�"`� Date: 1 ( l / <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 Service Request: "b' Service ll/ l�6 A Service Code 5 ,� <br /> Assigned to �/PLayee # /(p//1t�(/�/ Date001, Z;112 <br /> Fur. tion Required:��Y /1-10�V PROGRAM ELEMENT <br /> Date Service Completed <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt At Check # Recvd By <br /> l7 olo <br /> SUPV _/_/_� ACCT I _/_/_ (UNIT CLK _/_/_ <br />