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SERVICE RE�l1EST (SERVREQ) Revised 5/13/93 <br />ILITY ID # RECORD ID # / BILLING PARTY Y / C <br />`LOo SR # <br />I L I TY NAME rV- a k 5 a Y1� a fi L� <br />fE ADDRESS 0 W AID # <br />CITY G7 YI {� G CA ZIP FAC # <br />/OPERATOR L a � /T T S o 0� Y � l � �/ ' - (tel/% 1- BILLING PARTYT Y / <br />DBA PHONE #1 ( ) <br />ADDRESS PHONE 42 ( ) <br />CITY STATE ZIP <br />APN # Census --------- BOS Dist I I Location Code I I City Code ------ <br />CONTRACTOR and/or 1 <br />SERVICE REQUESTOR FQ Z1 C v O P c BILLINGl!PARTY O / ::N:] <br />DBA PHONE #1 (,10 9 � <br />MAILING ADDRESS 2, & I7 O 3 7 FAX # (� C _) - 3a� <br />CITY C– /1 b STATE 2 ZIP <br />BILLING ACKNOWLEDGEMENT: I, 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 billed to the party identified as the BILLING PARTY on <br />Page 1 of this form. <br />I also certify that I 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 Laws. <br />APPLICANT'S SIGNATURE : <br />Title Date: Z- / T <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 o Service Request: ' (r Service Code 1916 <br />Assigned t ; Employee # Date �z <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />• ox <br />FA <br />REHS I _/ / SUPV _/ / ACCT / i'3! UNIT CLK _1 / <br />