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SERVICE REQUEST (SERVREQ) Revised 8/ i/93 f� .R FACILITY ID # —'JRECORD ID # �O/Q !f40007 INVOICE # - FACILITY NAME �{�+L� JE�Z L-A,)E BILLING PARTY Y / N ) SITE ADDRESS 14'76-o- C is(A P10E-Z CITY L-�� CA ZIP g52 INV # OWNER/OPERATOR Sft^1 T�%� (Xy �/`� U ')7 / BILLING PARTY Y / N j DBA f�i./ LIG l/JOi KS ISE A-/2 T7�!E j 7 PHONE #1 ADDRESS f� �^ to PHONE #2 CITY J��-( - O.J STATE ZIP ��D d APN # Land Use Application # BOS Dist Location Codei=i rONTRACTOR and/or ERVICE REQUESTOR s ISE C+�u +nJ C d'I,c BILLING PARTY Y / N R DBA t- K�b i G LJi>l�(C S 7 �M PHONE 01 MAILING ADDRESS O F'C' ��>`Q FAX CITY CT�� .o\J STATE F ZIP °BILL.ING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on PagF 1 of this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN r JOAQUIN COUNTY Ordinance codesnand Standards, State and Federal laws. APPLICANT'S SIGNATURE : (; X° Title: �-kv l � aY�e�2d" Date: n AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 L L��u / X05 K.i oStc� M/4 r 17 E N�4^f« Service Code rJr Lskl") �" fJi Gv✓ ' Assigned to � - bLtV�t/P� Employee # 32-/ Date / J Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By r Rt HS / / SUPV �� / / / ACCT `/ / JUN17 CLK _!_/