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r-P7 14 <br /> } SERVICE REQUEST ooh tEH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # t� ) O Q y INVOICE # <br /> FACILITY NAME ��onr+.-,.. �-��� ^ rt BILLING PARTY Y / n <br /> SITE ADDRESS \::)A <br /> CITYCA zIP <br /> OWNER/OPERATOR V� t^cGY'�� ��(LC� BILLING PARTY / N <br /> DBA ` 0000 PHONE #1W-1%IL %OWN <br /> ��) - �✓ � <br /> ADDRESS `�� \ 6 NOPHQNE ri <br /> #2 C ) <br /> CITY r�� STATE � � <br /> APN # land Use Application <br /> CA <br /> n PEa�V`1 I =BOSDit Location Code <br /> 7v <br /> � 1 —Ci��7 "�2_"1 <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR--�Z LCa2 CF+�elMeMt,of'.` BILLING PARTY Y / p <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS FAX # ( ) <br /> CITY STATE zIP <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 prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE - �1 <br /> Title: L/mm: kM- %-1 nyircmr".k�" �t-AivlLL:6 Date: C Qpu� 91 lcy; o <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data 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 repres tative. <br /> Nature of Service Request: Service Code <br /> Q d 3 3 <br /> Assigned to Employee # L 4 Date 14 <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT pp <br /> N <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS / / SUPV / / ACCT <br /> JUNIT CLK <br /> -- <br />