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F <br />D <br />SERVICE REQUEST (SERVREQ) Revised 5/13/93 <br />FACILITY ID # <br />2�3� <br />RECORD—ID # <br />5 <br />BILLING PARTY <br />Y <br />FACILITY NAME Pt�CCJ Z��'', <br />SITE ADDRESS a4u,% <br />CITY c -X1 -N1;::^ CA ZIP -as a-O� <br />OWNER/OPERATOR BILLING PARTY Y / <br />DBA �O��k� �¢�'� PHONE #1 (- k" <br />APN # <br />ADDRESS L�-C��5- N�)f PHONE #2 ( ) <br />CITY `.tn \1(A STATE L t ZIP 11 O <br />Census F--------- I SOS Dist I I Location Code I I City Code I ------ <br />CONTRACTOR and/or <br />SERVICE REOUESTOR L o R BILLING PARTY / N <br />DBA �C3- �C_�\��i PHONE #1 ( <br />MAILING ADDRESSt.ylC\\FAX # ( <br />CITY �l L�> �Ptr.`c3]�� �� STATE C� ZIP �V� Y - <br />12 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all sit niftfo specific <br />PHS/EHD hourly charges associated with this facility or activity will be billed to the party identifiedh"E +�yl�t�lG6,QARTY on <br />Page 1 of this form. MAR ' C 5 <br />SAN JO , 1995 <br />I also certify that I have pre r this application and that the work to be performed will be d6k#AIC i�fe(l�jt(jNq�1 SAN <br />JOAQUIN COUNTY Ordinance Code a St r tate an Federal laws. EN ��R�NM�N TA H ALTH DIr'VVES <br />APPLICANT'S SIGNATURE <br />Title: t✓tvo CS.�.c�� C 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 <br />VL <br />Assigned to 4:!�-X4 � I,Ertployee # -2 U -3 Date -3—/_/� <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z 3 <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />? 3-( <br />t <br />'� <br />REHS I _/ / IW I _/_/_ I ACCT I f / I UNIT CLK I _/ ! <br />