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� l - 6-6d-1998 1 : 26PH FROM• � P-2 ' SERVICE REQUEST (EH 00 61) Revised 8/23/93 oc� FACILITY NAME l) t'el'l - L �— - BILLING PARY T / 0:� SITE ADDRESS CITYCA zip OWNER/OPERATOR CC-) JL7YN ��`l, .0 BILLING PARTY Y DVEI f PHONE #1 (— l0) 3 Sc 3—b i, DBA 1 _ ��.�_ ��%1 � t -. a ADDRESS r '9 % PHONE #2 ( ) CITY ',( Nf-� j �,�VL Z STATE C/19_ ZIP 945C APN # and Use Application # JEDist'F Location Cods CONTRACTOR and/or _ SERVICE RECUESTO—�Rjv'S,I/FKIC T-�C �'C�{yn�'1 CY`tl S�S�\y �C \�S 1�� BILLING PARTY Y� /(/ 4N Dg� �/� �ry 1 L� S 1 �1 t V l ��i � t /.� YY �� PHONE #1 l l'� k,) f -?L4L MAILING ADDRESS 1� 3�o N • ` ' t" ` FAX # C.TT STATE 21P i ) i BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of &alae, acknowledge that all site and/or pro)ect specific VHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Vage 1 of this form. PAYMEW 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with OIL SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. JUN 9 1998 APPLICANT'S SIGNATURE f %Il fLtj�l `i /a-/L4 n (IPUBLIC HEALTH SERVICES Title: i �� `� �CL * �A �Y Date: /(C:) ENVIRONMENTAL. HFALTH DIVISION 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 date "for 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 is provided to me or my representativc. Nature of service Request: C ISA y( V T► 1 j r IS—LLIAi 1� Assigned to �V V ` ��nL Employee # Service Code Date _�_/—LL—/'/ (� I Date Service Completed _J_� Further Action Required: T / N 1 PROGRAM ELEMENT Fee Amount Amant Pal Date of Payment ( 1� I� iNVo10E N Recvd By =FAMITYID 0V I G RECORD ID # oc� FACILITY NAME l) t'el'l - L �— - BILLING PARY T / 0:� SITE ADDRESS CITYCA zip OWNER/OPERATOR CC-) JL7YN ��`l, .0 BILLING PARTY Y DVEI f PHONE #1 (— l0) 3 Sc 3—b i, DBA 1 _ ��.�_ ��%1 � t -. a ADDRESS r '9 % PHONE #2 ( ) CITY ',( Nf-� j �,�VL Z STATE C/19_ ZIP 945C APN # and Use Application # JEDist'F Location Cods CONTRACTOR and/or _ SERVICE RECUESTO—�Rjv'S,I/FKIC T-�C �'C�{yn�'1 CY`tl S�S�\y �C \�S 1�� BILLING PARTY Y� /(/ 4N Dg� �/� �ry 1 L� S 1 �1 t V l ��i � t /.� YY �� PHONE #1 l l'� k,) f -?L4L MAILING ADDRESS 1� 3�o N • ` ' t" ` FAX # C.TT STATE 21P i ) i BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of &alae, acknowledge that all site and/or pro)ect specific VHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Vage 1 of this form. PAYMEW 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with OIL SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. JUN 9 1998 APPLICANT'S SIGNATURE f %Il fLtj�l `i /a-/L4 n (IPUBLIC HEALTH SERVICES Title: i �� `� �CL * �A �Y Date: /(C:) ENVIRONMENTAL. HFALTH DIVISION 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 date "for 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 is provided to me or my representativc. Nature of service Request: C ISA y( V T► 1 j r IS—LLIAi 1� Assigned to �V V ` ��nL Employee # Service Code Date _�_/—LL—/'/ (� I Date Service Completed _J_� Further Action Required: T / N 1 PROGRAM ELEMENT Fee Amount Amant Pal Date of Payment Payment Type Receipt # Check # Recvd By 49— [RENS / SUPV UNIT CLK __/�J