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SERVICE REQUEST (SERVREO) Revised 5/13/93 FACILITY ID # RECORD ID # 2 , BILLING PARTY Y / FACILITY NAME V''��O I7^-' SITE ADDRESS ��U� �r " ,jam CITY ZIP OWNER/OPERATOR `.Ih�0� Y ` f�tw S BILLING PARTY Y" )/ N 013 ��LO PHONE #1 ( ) ADDRESS "�� u�`n�C`� r �(��E PHONE #2 CITY �Q`�Gl STATE ZIP ®r APN # Census --------- BOS Dist Location Code City Code ------ CONTRACTOR and/or y� SERVICE REQUESTOR �G.N�� -\ C�rkwo. BILLING PARTYT Y / DBA � mct (a"M` PHONE #1 (SIO )_&I-i_- MAILING ADDRESS ,� `� �b \� � FAX it CITY h -1ov.�Wa STATE _ ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site acid/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the %LLING. TY on Page 1 of this form. 99ry�ltAR I also certify that I have red this application and that the work to be performed will be done in at �la pp 'L JOAQUIN COUNTY Ordinance Codes a Standar e a Fed era `NVIRON'iV1ENTALHEALTii01°�ISiON f APPLICANTS SIGNATURE r 2 a7 r Title: 2'�e�l— ' �� Date: -Z & /q7 AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it its^provided to me or my representative. o Nature of Service Request: �+��ll�-fr K 01 Service Code Assigned to _ c -U`1- Employee # Date -3L/ Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT c Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By W, -r RENS C / _/ _ SUPV _/ / ACCT _/ UNIT CLK _/ /