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SERVICE REQUEST (SERVREQ) Revised 5/13/93 <br /> FACILITY ID # RECORD ID # BILLING PARTY Y / N <br /> FACILITY NAME a/U <br /> SITE ADDRESS ?I ( S � �� /5 -- A P R 0 7 1994 <br /> CA ZIP % � <br /> CITY ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> BILLING <br /> OWNER/OPERATOR ly'+��-iL� ' —+ �-x- �—' _ _-_ PARTY <br /> DBA PHONE #1 (Z? Tt3 -6S 7 2-- <br /> ADD RE S S <br /> ADDRESS ^ Lp I -- PHONE #2{( ) <br /> CITY _� STATE ZIP <br /> APN # Census --------- JBOS Dist Location Code City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR cp <br /> BILLING PARTY Y / <br /> PHONE #1 (Z521)S G l� ' <br /> DBA y <br /> MAILING ADDRESS FAX <br /> 4 <br /> CITY _ _ STATE_ ZIP 2S 2— <br /> BILLING <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 bitted to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that 1 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 taws. <br /> APPLICANT'S SIGNATURE <br /> Title: D �i/� aYV �4 �U1 Date: r� <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 <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 /> REHS / / SUPV �/ / ACCT _/ J UNIT CLK /�f <br />