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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # I INVOICE # 1016 <br /> FACILITY NAME ✓� ��J � F— Z/ATS BILLING PARTY ( Y) / N <br /> SITE ADDRESSlam/ <br /> CITY / d� �PL��' CA ZIP <br /> OWNER/OPERATOR G'✓P '>�� f`� `��/�/ -S BILLING PARTY Y / N� <br /> DBA ` PHONE #1 �) 0 2-7 <br /> ADDRESS 7 /�( /tel l [� PHONE #2 <br /> CITY !N J��� STATE (�A ZIPL S / <br /> APN # Land Use Application # <br /> IF BOS Dist Location Code <br /> CONTRACTOR and/or a <br /> SERVICE REQUESTOR `— /✓e-e �� Gv✓Il i(UJ` BILLING PARTY T Y <br /> DBA PHONE #1 (C )_, �- �= <br /> MAILING ADDRESS '7�7(© il�(�1 Ke/D FAX # ( ) <br /> CITY <br /> � C - STATE ZIP �7Z � <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have preparedt application a that th w r o be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and/S1ndards, State ederal l ,... ,,, _ <br /> APPLICANT'S SIGNATURE C <br /> Title: r'C�`�-�' UJ`�G�' Date: , � <br /> -�-5`�5-MAR 2 9 1 <br /> OAQI CUUNTY <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the PUBLIC kjM16 IMM AL.1hicanX <br /> �Vil#E� of <br /> the property located at the above site address hereby authorize the release of any and all results, geotec nica ata 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: 6il�������ffptoyee <br /> /r'1 ( ll— a Service Code o5 <br /> Assigned to # r !� Date _/�/ jr -fs_ <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> U <br /> SUPV / / ACCT / / UNIT CLK _/ / <br />