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6-04-1 998 1 :26PLi FROM 1_1. 2 <br /> SERVICE REQUEST (EN 00 61) Revised 6/23/93 <br /> [FACILITY ID # y ,U (, I '� RECORD ID �l (l7 ( INVOICE M <br /> V V L J <br /> FACILITY NAME `�(]I.l�l l �Y l L .L__L BILLING PARTY Y / <br /> SITE ADDRESS <br /> CITY ; .��:�.L_ CA ZIP �2­1U <br /> OWNER/OPERATORtCO,IS-L.DC1 r L•i .� <br /> =BILLIKG <br /> ARTY Y / C <br /> e. DBA1l.�� ���%11 ( _- .C PHONE #1 ('...7 IO 13 3� <br /> t ADDRESS PHONE #2 ( ) <br /> CITY �(Y\(� �L T L�� Z STAT: C"e ZIP 9'4-S:, <br /> APN 0 Land Use Application # �— <br /> L <br /> M Dist I Location Code IF I <br /> CONTRACTOR end/or `J" <br /> SERVICE REQUESTOR -5 YL\r C 7-2:7�� C Xl BILLING PARTY T� /I/ff'' ++N <br /> PHONE *1 (L�Qp,) <br /> NAILING ADDRESS 1a3�e N. ` 1 - ln FAX # ( )� 1 0I351 - <br /> CIT _ STATE CA ZIP��1 <br /> t <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of simm, acknowledge that all site and/or project specific <br /> PNS/EHD hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on <br /> I <br /> ope 1 of this form. <br /> PAYMENT <br /> I also certify that I have prepared this application and that the work to be performed will be done in accorda*_ + _W <br /> spl <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal taws. <br /> APPLICANT'S SIGNATURE : v��.,Z/,L �� tom, JUNN <br /> 9 1998 <br /> (' SAN JOAQUIN COUNTY <br /> (1 <br /> Title: 1 -0�`� s�-x:j ��Y Date /�•i/C%r / J PUBLIC HEALTH SERVICES <br /> PVIRONMENTAL HEALTH DIVISION <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 date 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 we or my reprosentetivc. <br /> Nature of Service Request: vie/ Service Code <br /> Assigned to lily L/ y �V���v� Employee # _ _O( O W Date / L„ <br /> pate Service Completed further Action Required: T / N PROGRAM ELEMENT V30E <br /> ZJt <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check R Recvd By <br /> RENS \ UL SUPV _J—� ACCT ^_/�/ UNIT CLK __f�/ <br />