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d* I! SERVICE REOUEST r./ (SERVR ) sed /23/73 FACILITY ID N RECORD IDN INVOICE 0 FACILITY MAKE �T�/7Pl / OdtF+ BILLING PARTY SITE ADDRESS CITY ,f�G �ldy� CA ZIP OUNFR/OPERATOR ��d,{S6%,/,.�. L/�(/ /p �,,p BILLING PARTY Y / N DBA f9X�r/r�i�'7•de1� �'/-'��Gcy/ ?C / GYR's�� .2' PHONE N7 (—eeey 1„�ESXS ADDRESS -f��7 ,r! E�/�/1`��A. �f�A✓/t_� PHONE N2 CITY l,tY �'c`f�” If,.Y STATE ZIP [APB N p Lend Use Application N /;z� f._ BOS Dlat Location Code CONTRACTOR and/el- , SERVICE REOUESTOR /G ,vT® ..rG.�7� �''p;. Ve✓f BILLING PARTY Y / N DBA , 1 PHONE N1 NAILING ADDRESSy�/qy 9/ :�J<!/.f/�N�^i�9/"P'tr FAX N CITY . a,GT, ✓ STATE _._ ZIP BILLING ACKNONLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site end/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party Identif led as the BILLING PARTY on Page T of this form. I also certify that I have prepared this application and that the work to be performed will be done In accordance with ell SAN JOAOUIN COUNTY Ordinance Codes and SStarderds, State and Federal laws. APPLICANT'S SIGNATURE tTltte-- ON AUTHORIZATITo RELEASE INFoRM11T)oN: 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 date and/or envirormental/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as 9t is available and at the Same time it is provided to me or my representative. Nature of Service Request- , V / .t:� dee-" Service Lode .S Assigned to ��.�' f: �at'/�.�r+ Employee N e, Date Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT / - Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By REHS _/ / SUPV _/ / ACCT _/ / UNIT CLK _/ /