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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME C/ / `�YI� BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY �/V/�� CA ZIP <br /> OWNER/OPERATOR !�� BILLING PARTY Y / N <br /> DBA J PHONE #1 ( ) <br /> ADDRESS y'2�D/ ' v vy �J PHONE #2 <br /> / ( ) <br /> CITY STATE Ot 4 ZIP <br /> APN # Land Use Application # <br /> fff BF- OS Dist Location Code <br /> CONTRACTOR and/or �-� <br /> SERVICE REQUESTOR v / �BILLINGRTY <br /> DBA aO-jJ / J PHONE #1 <br /> I ( ) <br /> MAILING ADDRESS 22,7 Z/ A"/"1, FAX # ( ) <br /> CITY STATE ZIP 7J V3 J 7O <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. pp rr����;;� yy-- <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in FaA9NF,9lth all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> R'ECE1VFr) <br /> J U L 111995 <br /> APPLICANT'S SIGNATURE SAN JOAQL,.fV I,OLN'TY <br /> Date: PUBLIC HEALTH SERVICES <br /> Title: M1HUNIMENTTL HEALTH DIVISION <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 /> Service Code <br /> Nature of Service Request: <br /> Assigned to Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N [PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 7b� ? qy aySG <br /> �f <br /> RENS S� I /—LL/ SUPV <br />