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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> =FACILITY ID # RECORD ID # r l INVOICE # <br /> FACILITY NAME �L G-p�JSON �T7�}' � �� BILLING PARTY Y /( <br /> SITE ADDRESS C,J 0� <br /> CITYCA zip 5220 <br /> OWNER/OPERATOR W So7-�,47�-5 BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS Z Z - C-{�u l�C N S� PHONE #2 ( ) <br /> CITY LO Q r STATE CA- ZIP 7 S��0 <br /> APNIFLan <br /> # d Use Application # <br /> M 1,_ <1 1�cS BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR ��Q LI/ 48/46�� //� Z�'z`—/`f =BILLING PARTY Y / N <br /> DBA 7 PHONE #1 O _'•(.;� (off / �/ <br /> MAILING ADDRESS J 3 w E L/� S T FAX # ( ) <br /> CITY STATE CA ZIP � 5,:x`FC7 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <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 /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: Service Code S 2 2 <br /> Assigned to y-e I✓r (" Employee # ` Date <br /> Date Service Completed 5 / / �_� Further Action Required: Y / N PROGRAM ELEMENT �• -� <br /> Fee! Amount Amount Paid Date of Payment Payment T Receipt # Check # Recvd By <br /> [REHS /�� _/ SUPV _/ / ACCT -:-L/—z7—/]yUNIT CLK _/ / <br />