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iSERVICE REQUEST i (EH 00 61) Revised 8/23/93 <br />FACILITY ID # I I RECORD ID # I V I INVOICE # <br />FACILITY NAME 7 %r-,, r A :Z►0til BILLING PARTY Y / N <br />SITE ADDRESS %'S -7`l —1 LV -y <br />CITY�tZAsy CA ZIP —1 & _ <br />OWNER/OPERATOR Tp S�2 IP141I &G4C'fiA1 CC BILLING PARTY Y / N <br />DBA l/I ✓l PHONE #1 ( �1 ) - <br />ADDRESS �t? /J �' AL- Hoo PHONE #2 (4;'7�) zoo - L4':3S5 <br />CITYSTATE _A ':iZ,_ ZIP gGijJl <br />APN #— Land Use Application # <br />BOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR <br />DBA <br />MAILING ADDRESS <br />iZ t �i n 4- L_�z / A -Fr- . % Tic <br />3S7_�,?_arJ' <br />IANC o CO= --VV-&' CA <br />i <br />BILLING PARTY 1 -/ Y // N <br />PHONE #1 (C,L/ ) <br />X16 635 z'�4N CT,atY� <br />FAX # ( cjtL ) 6-5s- TA, -T) <br />CITY �JAC,z.Ar+,ic/JTc e STATE _('-,Q_ ZIP C�!-SR7_:3 <br />T -Ai T Cf grA r T - 'Pv •J '9d-z^i r <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator cr agent of same, acknowledge that all site and/or project specific <br />PHS/EHD hourly charges associated with this facility or activ�ty will be billed to the party identified as the BILLING PARTY on <br />Page 1 of this form."r- <br />R <br />I also certify that I have prepared this applica on and that the work to be performed will be done in accVMncc� Wt4h all SAN <br />JOAQUIN COUNTY Ordinance Codes and Stan dards,.fie and Federal laws. JUN 2 1998 <br />APPLICANT'S SIGNATURE : <br />v HEALTH ENVIRONM SFlatij�-S <br />ENTAL HEALTH LiVISIQPd <br />Title: _(�`p � �� �� Date: 3, i&i4S 7_ 199 � <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 of Service Request: Service Code I L b <br />Assigned to Employee # 9 / Date / �. / I <br />t <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT a <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />/ / <br />fa .�q r <br />4/--14qq <br />1 1 M to <br />FEEZ-' <br />SUPV <br />I_/ / <br />ACCT <br />_/ / <br />UNIT CLK <br />/ / <br />