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SERVICE REQUEST • (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID it 7"1 INVOICE <br /> FACILITY NAME w �� s4, 0.,, � -;tt J 7 "S BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> -T <br /> OWNER/OPERATOR i,. I� S74lr� )44af< , T--",c BILLING PARTY Y N <br /> DBA PHONE #1 ( ,5" o ks-C)n <br /> ADDRESS �L1 X,LS7'Ys PHONE #2 ( ) <br /> CITY _ v✓1 d A� / STATE Cl4 ZIP 2`� 0`J 7 <br /> APN # Land Use Application # <br /> BOS Dist location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR �i4e� ---�- ��JA/)/L4c d 2 S X-A- BILLING PARTY <br /> DBA PHONE #1 <br /> MAILING ADDRESS S�S j'i w'�I''t �c/2 FAX # ( ) <br /> CITY �TlfcK�d STATE CtJ ZIP 9S'Z d <br /> BILLING ACKNOWLEDGEMENT: 1, 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 "he BILLING PARTY on <br /> Page 1 of this form. <br /> also certify that 1 have prepared this application and that the work to be performed will be d jK'�cccor e with all SAN <br /> 'JOAQUIN COUNTY Ordinance Codes and Standar s, State federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: f2('c 4/'c� .t'/✓J��11�1,1bI,f%�1/T�4 /T�7i�l�2 f Dater`f// 7 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, a oor 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 some time it is provided to me or my representative. <br /> Nature of Service Request: &,0A l'\ ? Q Service?Code <br /> Assigned to Employee # `� Date J <br /> -A117 <br /> Assigned <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 /> �. 3 aZ 3� 3�a1o1 ✓ -P y95S�J <br /> SUPV / / ACCT UNIT UNIT CLK _/ / <br />