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SERVICE REQUEST (SERVREG) Revised 8/23/93 FACILITY IDN I O�� RECORD IDN INVOICE ►At IL11V NAME — GlJ _ N�°� G/ G�eieM�� / G �' 7 OILLING PARTY 1 Y / SITE ADDRESS CITY CA 21P � _ owpirR/OPERATOR Gl UIJI/ ti'f�1�3iV7" 'L��'T16 Jr �' � BILLING PARTY Y / N DBA PHONE 01•(-6 0 ) ADDRESS PHONE 02 ( ) CITY STATE ZIP Arm Nr —Land Use Application N 80S Dist Location Code CONIRACTOR and/or SERVICE REOUESTOR /� t�r�ieDG4� -�7?Sti�;�i / '` 9' BILLING PARTY Y / N DBA - PHONE N1 ( 67e) MAILING ADDRESS S O Y�"�✓� rAx N CITY /v � 1JT // STATE ZiP Nil-LING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site aril/or project specific PHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Pagorl of this form. I nlso certify that 1 have prepared this application and that the work to be performed will be done iInt accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE Title- Date: AIITItORIZATiON TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 la available and at the same time it is provided to me or my representative. Nnture of Service Request: �Y-�.S c4lee-- Service Code Assigned tozti/ Employee N '0/ 7 bete Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recyd By RFHS / / SUP V _/ / ACCT _/ / UNIT*CLK – NEW t