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z0'39Cd 8 :80 s6. bz Jnd <br /> e <br /> SERVICE REQUEST (SERVRIO) Revised B/M/" <br /> FACILITY IDM I REOORD ID 11 INVOICE d <br /> FACILITY NAME ^�J�I�C�! PILLING PARTY T / oN <br /> SITE ADDRESS :; -1 3 O _- <br /> CITY ✓`" CA ZIP <br /> i ww� <br /> X OWNER/OPERATOR /�+��� 1'r BILLING PARTY t Y / N <br /> DBA ` ` - PHONE #1 t ZU y ) 9H(v.0 rj y <br /> ADDRESS - a� " �O'w""7 - POW 02 <br /> CITY STATE (7 ZIP '� 3 <br /> F Amw r Lord Use Appl I cat l on P <br /> BOR Oist loeatlon Godo <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR �C,' � BILLING PARTY V / N <br /> I k cc <br /> ORA PNON1 Int ( 9 )-±3-3 - <br /> 1 yob' <br /> MAILING ADDRESS / I Gt//K���Q�'� � " ` IN( / ( ) _ 3�9 7 <br /> CITYlv 77( � t S STATE ZIP 74 2— <br /> BILLING ACKNOWLEDGEMENT: 1, thq undersigned owner, operator or agent of some, acknowledge that all site and/or proleet speeifle <br /> PHS/END hourly charges associstAd with this faculty or activity rill be billed to the party Identified as the BILLING PMTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this aMt lcation and that the work to be porforsiod will be done In oceordenee with all SAN <br /> JOAQUIN COUNTY Ordinance Codes 9nd Ste . State and Feder l <br /> l� APPLICANT'S SIGNATURE z T` <br /> Title• !L� Dete•�C �/�y� <br /> AUTHORIZATION TO RELEASE INFORMATIONr in oddition to the above, when appllcable, 1, the owner, operator or agent of saere, of <br /> the property located at the above alto address hereby authorize the release of any and ell moults, geotechnical data and/or <br /> environmental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE! ENVIRONMENTAL REALTM DIVISION as soon ea <br /> It Is available and at the same 1. <br /> time it Is provided to me or my representative. <br /> Nature of Service Request: 6 service Cob '3/a <br /> Ageigned to Employee 0 O L D Dote •�/�/ <br /> Date Service Completed ^�( / Further Action Required: E / N PROGRAM ELEKNT <br /> Fee Amount Amount Pe d Oete of Payment Payment Type Receipt / Cheek 0 Reevd By <br /> LEH <br /> / SUPV _�iJ ACCT / / UNIT CLK --- /____�/ >t <br /> Z d sb :BO 96/t72/80 WON A <br />