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SERVICE REQUEST (SERVREO) Revised 8/23/73 <br /> YYY g <br /> TACILITY ID R RECORD ID !! F 1�NVOICE N�.3 `� 3 <br /> FACILItY NAME �������� �ve� �v�E �.4s✓on�G ILLING PARTY <br /> SITE ADDRESS C /e /�O 66 C6, # - <br /> CITY �/°��y ( ZIP gS.3'7G� <br /> Y <br /> OWNrR/OPERATOR �'ti%fi�'1' ��i�50�/ ��(s� ��/ 50'tt BILLINGPARTY / N <br /> DBA �J,C PHONE N1 ( ) <br /> ADDRESS _ / 0 0 1q-0C PHONE N2 <br /> CITY /1,.L�tr°t'MO�P—E STATE ZiP <br /> APN N —Land Use ApplIcat Ion N <br /> FBOS Dist Location Code <br /> CONiRACiOR and/or <br /> FeILLING PARTY Y / N <br /> SERVICE REOUESTOR <br /> DAA PHONE 01 <br /> ( ) " <br /> MAILING ADDRESS FAX N <br /> CITY STATE _ ZIP <br /> RILIING ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of snme, acknowledge that all site and/or project specific <br /> P11S/EHD hourly charges associated with this facility or activity will be billed o the party identified as the BILLING PARTY on <br /> Pnge•1 of this f m. += P L �,,. t)r 23 80 �t1 <br /> 3�• At. �3. 1� �' �,, 7�9 <br /> 1200 3 3q S T/J v . <br /> I nlso certify that i have prepared this application and that the work to be performed will be dole in accordance with ell �/IN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUiHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the owner, operator or agent of Bare, of <br /> the property locnted at the above Bite address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirormental/Rite assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is nvallnble and at the snme time It Is provided to me or my representative. <br /> – - Service Code <br /> Nnture of Service Request— <br /> Assigned to 6-fl1 �NyE��/ EnplKyee N �' 2--- Date <br /> Dnte Service Completed / / Further Action Required: Y / N PROGRAM ELEMENTS, L <br /> Fee Amount Amou�PIdDate of Payment Payment Type Receipt N Check N Recvd By <br /> c, l.54. <br /> RENS <br /> EPV _/ / ACT / / UNIT'CLK _/ / <br />