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SERVICE REQUEST (Ell 00 61) Revised 8/23/93 I k14 FACILITY NAME o ) ,✓ SITE ADDRESS_ CITY f4 OWNER/OPERATOR DBA CA Z I P ` �/-D / m BILLING PARTY I / BILLING PARTY I Y / N PHONE N1 ( 11 ) -2-77--2 --?::,1 PHONE N2 ( ) ADDRESS vv yv�w/�/js CITY ✓/ STATE 21 u _a — ZIP FAPN N IF Land Use Application N 8OS Dist Location Code !� CONIRAP.IOR aril/or — C� %�n�---��/I l_.n SERVIP,E RF.orawl OR BILLING "PAAR�T�YC Y / N DRA ��T PIIONE N1 ( �"" )� r7 MAILING ADDRESS CITY 5k) FAX N (20L)." 2— STATE (7Gt- ZIP !� ;-D BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of snore, acknowledge that all site and/or project specific PIIS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. PAYMENT 1 also certify that I have prepared this application and that the work to be performR E_MME ith all SANed will be done JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. c AUG 2 t1 1997 APPLICANT'S SIGNATURE SAN JOAQUIN COUNTY Ell PUBLIC HEALTH SERVICES Date: ENVIRONMEUTA1. HEALTH DIVISION AUINOR17AT10N TO RELEASE INFORMATION: In n6lition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site nddress hereby authorize the release of any arxf all results, geotechnicnl data and/or envirorvrrental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as rr,�-1 nt the sone tiny_ it Is provided to ore or my representative. Nature of Service Re(frest: Assigrred to -,-�,Enployee N Date Service Cerrpleted // _._ Further Action Required: Y / N Fee Amount Amount Paid nV S -I CTel - S)—__/ �0 I S Q Date of Payment t' m//AW S Date _?/ 2. ervice / PROGRAM ELEMENT Z 75; C) Payment Type I Receipt N I Check N I Recvd By ACCT //� 1 rrNIT CLK I / / ��RECORDID INVOICE NFACILITY ID k14 FACILITY NAME o ) ,✓ SITE ADDRESS_ CITY f4 OWNER/OPERATOR DBA CA Z I P ` �/-D / m BILLING PARTY I / BILLING PARTY I Y / N PHONE N1 ( 11 ) -2-77--2 --?::,1 PHONE N2 ( ) ADDRESS vv yv�w/�/js CITY ✓/ STATE 21 u _a — ZIP FAPN N IF Land Use Application N 8OS Dist Location Code !� CONIRAP.IOR aril/or — C� %�n�---��/I l_.n SERVIP,E RF.orawl OR BILLING "PAAR�T�YC Y / N DRA ��T PIIONE N1 ( �"" )� r7 MAILING ADDRESS CITY 5k) FAX N (20L)." 2— STATE (7Gt- ZIP !� ;-D BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of snore, acknowledge that all site and/or project specific PIIS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. PAYMENT 1 also certify that I have prepared this application and that the work to be performR E_MME ith all SANed will be done JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. c AUG 2 t1 1997 APPLICANT'S SIGNATURE SAN JOAQUIN COUNTY Ell PUBLIC HEALTH SERVICES Date: ENVIRONMEUTA1. HEALTH DIVISION AUINOR17AT10N TO RELEASE INFORMATION: In n6lition to the above, when applicable, 1, the owner, operator or agent of same, of the property located at the above site nddress hereby authorize the release of any arxf all results, geotechnicnl data and/or envirorvrrental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as rr,�-1 nt the sone tiny_ it Is provided to ore or my representative. Nature of Service Re(frest: Assigrred to -,-�,Enployee N Date Service Cerrpleted // _._ Further Action Required: Y / N Fee Amount Amount Paid nV S -I CTel - S)—__/ �0 I S Q Date of Payment t' m//AW S Date _?/ 2. ervice / PROGRAM ELEMENT Z 75; C) Payment Type I Receipt N I Check N I Recvd By ACCT //� 1 rrNIT CLK I / /