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1-N, <br /> SERVICE REQUEST (SERVREQ) Revised 8/02/93 <br /> d <br /> FACILTY ID # RECORD ID # a INVOICE # <br /> FACILITY NAME �5- e4) t tth-6-C/ PARTY Y / N <br /> SITE ADDRESS <br /> JC <br /> CITY � iiF�-� ZIP <br /> SL6 <br /> OWNER/OPERATOR J Ju� ll BILLING PARTY Y / N <br /> DBA , PHONE #1 ( � v I ) !� 36&6 <br /> ADDRESSI d l v I PHONE #2 ( ) <br /> ,,QQ,� <br /> CITY S- � STATE C✓�� ZIP [� <br /> APN # Census Li <br /> SOS Dist Location Code City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR 1 �d�-� Q/r.-�l"^ =BILLING PARTY Y / <br /> DBA S�)" PHONE #1 <br /> -T /1� <br /> MAILING ADDRESS ,/T FAX # <br /> VALCITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of samell 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 <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 /> N <br /> APPLICANT'S SIGNATURE <br /> Title:-- Date: <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 oif any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTNgSERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> i <br /> Nature of Service Request: Z iN�� .+ Service Code <br /> Assigned to <br /> k41� Employee # 9�� Date L <br /> y; 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 /> ]i <br /> REHS _/_f SUPV "1 _/_� ACCT �C3_II I�/"'�L UNIT CLK <br />