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SERVICE REQUEST (Ell 00 61) Revised 8/23/93 <br /> FACILITY 10 dl RECORD Ib N Q/ �a INVOICE k Y- <br /> ,» <br /> f <br /> i <br /> FACILITY NAME BILLING PARTY Y / H <br /> Sift ADDRESS <br /> IFN <br /> CITY CA zip <br /> PAYMENT <br /> ' <br /> 01JNER/OPERATOR RECEIVED BILLING PAR1Y Y / N <br /> 2 6 <br /> BBA SAN is I > ., PHONE N1 <br /> ` PUBLIC 1.1EAI_T,; SERB = <br /> t ADDRESS ENVIRONMENTAL HLAJ I H D:: _ PHONE 02 <br /> fSTATE ZIP <br /> I CITY <br /> —APN IT —Lend Use ApplIcat Ion k ,{{ <br /> Bos Dist Location Code pft� <br /> CONTRACTOR and/or 7 t , <br /> SERVICE REQUESTOR �7('r �LC f//C� luo w BILLING PARTY Y <br /> �f / /�� PHONE Ni ( ) (c <br /> s DIIA / Ver, <br /> / <br /> MAILING ADDRESS 1-e0 /� �� p «`7 FAX <br /> f <br /> CITY STATE ZIP <br /> hILLING ACKNOWLEDGEMENT! I, the undersigned owner, operator or agent of same, acknowledge that all site end/or project epee I c,,i, <br /> PIIS/EIID hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on' -.4,, <br /> Page 1 of this form. <br /> l <br /> 1 nlso certify thnt •1 have prepared this application and that the work to be performed will be done In agSQr r l th all SAN <br /> .7 <br /> ' JOAQUIN COUNTY Ordinance Codes and standards, State and Federal lows. f _. <br /> AUG 2 6 i999 y <br /> APPLICANt'S SIGNATURE SANr <br /> r'USLIC F�Hl1l UV y <br /> ! Title: Dnte! _ ALTHSEIVICES ;) <br /> I EPaTgI MEALT1 l <br /> AUIHORIZAtION 10 RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of some, 0i <br /> tiara <br /> i the property located at the above site address hereby authorize the release of any and all results, geotechnical data end/oh <br /> ! envirorniental/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon no <br /> it Is available and at the same time it Is provided to we or my representative. <br /> Nature of Service Reciest: C rno Z ! /- Service code /• <br /> Assigned to Enployee M Date <br /> y Date Service Completed / / <br /> Further Action Required: Y / N PROGRAM ELEMENT <br /> l 'i <br /> Fee Amount Amount Paid Date of Payment Payment type Receipt M Check N Recvd by ''$s <br /> r <br /> RENS ACCTUNIT CLK <br /> r — <br />