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SERVICE REQUEST • (SERVREQ) Revised 8/23/43 FACILITY ID # Q' RECORD ID INVOICE * FACILITY NAME / / / ►✓� ` / BILLING PARTY Y / N SITE ADDRESS /Cd 6 l lgIq CITY CA ZIP-- �� ` r BILLING PARTY Y f N OWNER/OPERATOR y�� DBA T)e !n f— i)2 HONE *1 ( ) ADDRESS �•3te PHONE 02 ( ) CITY STATE " ZIP �] APN N ..- — Land Use Application # !OS Dist Location Code CONTRACTOR and/or SERVICE REQUESTOR b�� -Q� I-X I eS BILLING PARTY /, Y y / N DBA PHONE #1 ( )_6 '�� _ MAILING ADDRESS 3 7 A/IC_ Blu4m ( ) CITY Q. CSU_/LASJC-C—� STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD 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. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. APPLICANT'S SIGNATURE Title: Date: 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 is provided to me or my representative. P—LNature of Service Request:/ Service Code (6"UDate Assigned to UI, /ll '</ Employee �! Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT o Fee Amount Amount Paid Date of Payment Payment Type Receipt * Check * Recvd By a�H — / / HE / h UNIT CLK S SUPV L ra 1-1,114nd ow S.