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SERVICE REQUEST (ETI 00 61) Revised 9/23/93 FACILITY ID M RECORD Ib b INVOICE M ~*, FACILITY NAME C- �7L h BILLING PARTY Y / SITE ADDRESS I UL ) `7 L S� iJ(C✓I *�G�/ �'`" r ' r city j&2400 � CA ZIP Z_36 t; OWNER/OPERATOR C�(t?��G� / CCJ�/` ¢� BILLING PARTY Y .,r DtlA PHONE NI ) ; ADDRESS �7 ` �y✓l( rC Z ter' PHONE N2 �a city ,�¢f�t�^5/�n STATE _ zip r APN N —Lend Use Application N DOS Dist location Code f _ � t CONTRACIOR nrxl/or r ` SERVICE REQUESIOR U� BILLING PARTY DBA �f Ll�� r . l GL PHONE Ni ( –cf? 6 )1� 3 ( ) FAX k NAILING ADDRESS �• � � •"�" 7 7 4_1 ` CITY (. � 1� STATE `� ZIP e/ G - • fid ' BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site end/or project specific,,, PIIS/EIID hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on:; ;,^ 4.y. r Page 1 of this form. ( 1 nlso certify thnt -1 have prepnred this application and that the work to be performed will be done In accordance with all SAN r JOAQUIN COUNTY Ordinance des end Stondards, state end Federal laws. APPLICANT'S SIGNATURE i '. Title: F AUTHORIZAtIoN TO RELEASE INfoRMA110N: In addition to the above, when applicable, I, the owner, operator or agent of some, of the property located at the above sit@ address hereby authorize the release of any and all results, geotechnical data and/oh environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as It Is available and at the sane time it Is provided to we or my representative. r Nature of Service Request: Service Code �• _ I C,+ Assigned to nployee M U Date Q4 } f. Completed m C i S Date Service opr; i /� Further Action Required: Y / ( N / PROGRAM ELEMENT ` Fee Amount Amount Paid bate of Payment Payment type Receipt M Check A Recvd By 90 REMS C /Z� SUPV _/ / ACCT �/ / UNIT CLK �/ /