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B-12-1997 3 : 435PH FACILITY ID N FROP 1 P- 2 SERVICE REQUEST (EH UO 61) Revised 8/23 RECORD ID # `3 L/ 1 INVOICE # BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of some, acknowtedge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on Page 1 of this form. PAYMENT I also certify that I have prepared this application and that the work to be performed wilt be done in'cXM1® alt SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Fedgrat laws. APPLICANT'S SIGNATURE : ,(�� AUG 2 5 1997 SAN JO HEALTH SERVICCOUNTES EIQ PCIA01 W1ENTAL HEALTH IDIVISION AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of smoc, of the property located at the above site address hereby authorize the release of any and alt results, geotechnical data and/or envirorxnentol/site assessment information to SAN JOAOUIN 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. Nature of Service Request: \Service Code Assigned to ) 5 Employee # 9-0-3 Date Date Service Completed / _/ Further Action Required: Y / N PROGRAM ELEMENT li 3 d b Fee Amount Amount Paid a of Payment fps;zt Type Receip Check # Recvd 13y FACILITY NAME -�0 C�2t/ D BILLING PARTY Y SITE ADDRESS l Yo3 CV&J-79V CITY CA 21P 9520, OWNER/OPERATOR 81LLING PARTY Y f'` N DBA PHONE 01 ADDRESS PHONE #2 CITY - _ STATE ZIP APN N - Land Use Application N F F �,— BOS Dist Location Code CONTRACTOR and/or SERVICE REOUESTOft ��9L/Fy/c/t%/� � / SCj�II�C s, �j(lC 81LLING PARTY / N DBA S,QM F c PHONE #1 MAILING ADDRESS N3 Z E___ C--' 7'q FAX # (71Y ).! 15� - i?9y80 _ CITY 461A STATE zip 92� BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of some, acknowtedge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on Page 1 of this form. PAYMENT I also certify that I have prepared this application and that the work to be performed wilt be done in'cXM1® alt SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Fedgrat laws. APPLICANT'S SIGNATURE : ,(�� AUG 2 5 1997 SAN JO HEALTH SERVICCOUNTES EIQ PCIA01 W1ENTAL HEALTH IDIVISION AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of smoc, of the property located at the above site address hereby authorize the release of any and alt results, geotechnical data and/or envirorxnentol/site assessment information to SAN JOAOUIN 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. Nature of Service Request: \Service Code Assigned to ) 5 Employee # 9-0-3 Date Date Service Completed / _/ Further Action Required: Y / N PROGRAM ELEMENT li 3 d b Fee Amount Amount Paid a of Payment fps;zt Type Receip Check # Recvd 13y Z