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SERVICE REQUEST CEH 00 61)Re ised 8/23/93 FACILITY NAME TT BILLING PARTY/ N SITE ADDRESS �� J CITY G&2O / CA ZIP % z OWNER/OPERATOR BILLING PARTY Y / DBA PHONE #1 ( ) ADDRESS PHONE #2 ( ) CITY STATE ZIP APN # F Land Use Application # rBOS Dist Location Code CONTRACTOR and/or SERVICE REQUESTOR✓/�'e�� / i'/ •G/ `L— BILLING PARTY / Q DBA PHONE #1 ( ) MAILING ADDRESS FAX # ( ) CITY STATE ZIP PAYMENT BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowled Jr4tp% F1)L W and/or project specific W PHS/END hourly charges associated with this facility or activity will be billed to the ?.de7ti a, the BILLING PARTY on Page 1 of this form. SAN JOAQUIN CULINfY PU19LIC HEALTH SERVICES I also certify that I have prepared this application and that the work to be pMlSAQNV9NT&"TW WVb$Nl ke with all SAN JOAQUIN COUNTY Ordinance Codes and Atgndards: State and F9gieral laws. LICANT'S SIGNATURE : Title: IL" /1' / / Date: ---;7 / 2 / Z —S AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: IA wtl �� I I Service Code Assigned to _1�1.�, Employee # Date Service Completed / / Further Action Required: Y / N Date -L / Z�_/!I C5 1 PROGRAM ELEMENT Fee Amount r Date of Payment FACILITY ID # RECORD ID # Check # INVOICE, I FACILITY NAME TT BILLING PARTY/ N SITE ADDRESS �� J CITY G&2O / CA ZIP % z OWNER/OPERATOR BILLING PARTY Y / DBA PHONE #1 ( ) ADDRESS PHONE #2 ( ) CITY STATE ZIP APN # F Land Use Application # rBOS Dist Location Code CONTRACTOR and/or SERVICE REQUESTOR✓/�'e�� / i'/ •G/ `L— BILLING PARTY / Q DBA PHONE #1 ( ) MAILING ADDRESS FAX # ( ) CITY STATE ZIP PAYMENT BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowled Jr4tp% F1)L W and/or project specific W PHS/END hourly charges associated with this facility or activity will be billed to the ?.de7ti a, the BILLING PARTY on Page 1 of this form. SAN JOAQUIN CULINfY PU19LIC HEALTH SERVICES I also certify that I have prepared this application and that the work to be pMlSAQNV9NT&"TW WVb$Nl ke with all SAN JOAQUIN COUNTY Ordinance Codes and Atgndards: State and F9gieral laws. LICANT'S SIGNATURE : Title: IL" /1' / / Date: ---;7 / 2 / Z —S AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to SAN JOAQUIN 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: IA wtl �� I I Service Code Assigned to _1�1.�, Employee # Date Service Completed / / Further Action Required: Y / N Date -L / Z�_/!I C5 1 PROGRAM ELEMENT REHS Fee Amount Amount Paid Date of Payment Payment T Receipt # Check # Recvd By 70 REHS _/ / SUPV _/ / ACCT/ / �F UNIT CLK 1