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SERVICE REQUEST • (SERVREQ) Revised 5/13/93 <br /> FACILITY ID # -2;AV- t RECORD ID # 5�� 3 BILLING PARTY Y / N <br /> FACILITY NAME <br /> SITE ADDRESS <br /> CITYy`\��<e`` CA ZIP <br /> NE /OP RATO V `� `C BILLING PARTY Y / <br /> DBA �`W� 2 PHONE #1 +0 <br /> ADDRESS " PHONE #2 ( - <br /> CITY STATE ZIP <br /> APN # Census --------- BOS Dist Location Code City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR c_o BILLING PARTY <br /> DBA C '�, C Com.\`1Z� PHONE #1 ( slo r� � <br /> MAILING ADDRESS i \ )eeb\\ \\\� \J - FAX # 410 ) - <br /> CITY �-� �O���t O STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site andel/dor project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identifiePAinEllf� f PARTY on <br /> Page 1 of this form. RECEIVED Q <br /> I also certify that I have pr ed this application and that the work to be performed will be done inl2Ardanle ti'fh'all SAN <br /> JOAQUIN COUNTY Ordinance Codes a Sta ands, State and Federal taws. $61N,l��li11N(`,AUNTY <br /> ptaBLl k� >rTli 5[R. V►CES <br /> APPLICANT'S SIGNATURE ENVIRONMNfiA�HALT�i01vIS�ON <br /> Title: �rU\`�Uny ` \� ����\d3�LI� Date:. ,'1 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> r 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 /> Assigned to � X� Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 3 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> (_A <br /> REHS _/ / SUP _/ / ACCT /^ UNIT CLK _/ / <br />