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6=04-1997 11 . 17AM FROM p <br /> SERVICE REQUEST CEH 00 611 Revised 8/73/93 <br /> FACILITY ID # RECORD ID # F-7- I INVOICE # <br /> FACILITY NAME !Z I �� ,c 'JI� � S I BILLING PARTY y / <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR 1/U I l-14,Am PC)UI-I BILLING PARTY Y• /�J <br /> DBA PHONE #1 ( .2,-)t ) 5 34Y2 <br /> ADDRESS U 3J� -FE�1t_AC,— DIZ;fE PHONE *2 <br /> CITY STATE —CAr zip /.5 2-/2- <br /> APN # Land Use Application # <br /> ! BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING PARTY <br /> DBA ATTN'. "TRUGw Ci m,--,1 PHONE dt1 { y�6 )�4 y - (�3 78 _ <br /> HAILING ADDRESS 1,_Z>L FAX # C. -5313 <br /> =-' -5313 <br /> CITY STATE lip 4S8-6 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/END hourly charges associated with this facility or activity will be bitted to the party identified as the BIL'tING PARTY on <br /> Page 1 of this form_ <br /> I also certify that 1 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 /> APPLICANT'S SIGNATURE <br /> Title:: . Date- — <br /> AUTHORIZATION TO RELEASE INFORMIATION- In addition to the above, when applicable, 1, 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 data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISI15H as soon as <br /> it is available and at the sama time it is provided to me or my representative. %Y <br /> �7yti" <br /> Nature of Ser este Service Code qbO <br /> Assigned to -2 Employee # � }� Date _(a <br /> Date Service Completed _ Further Action Required: Y J N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check # Recvd By <br />