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SERVICE REQUEST " bER ed 8/23/93 jFACILITY ID # RECORD ID # �O l %� ?MVOICE # FACILITY NAME �GLON yc..i.{/l/G/f u--!/LQ�L� BILLING SITE ADDRESS 2 / �2 �' 2 92 E . C an/ E 7•/Z6,. 212. CITY O/+z,12/---C.-- e/ CA ZIP OWNER/OPERATOR IVOI2M %a" �D '3217 3 % /SLI Thi ' y NU 17— 7-1) IV Payment Type BILLING PARTY # Recvd By PHONE 02 C 7 DBA Z5G/-}LU yhI /Z/iN �-hI �01.Un� .JOII✓% VeN:&PHONE #1 CITY MAILING ADDRESS 1rLr'vl.. o,vi S7 n FAX # ( ) CITY iULIG TU(�' STATE C/4 ZIP Y S ZU BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHO hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. I also certify that I have pr r this applic i a that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance C s a StarKleTds, e F rel Laws. ;:ES EN, APPLICANT'S SIGNATURE Title• 21 Liz Date: 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 [MINTY 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: Assigned to 4=�7 �o•d�l`C (� Date Service Completed �` /� / Employee # b � a b Action Required: Y / N Service Code —2c'/�-/ Date PROGRAM ELEMENT Fee Amount �D '3217 3 % /SLI Thi / 2D Payment Type ADDRESS # Recvd By PHONE 02 C 7 /C% Z�G�4U/'/ G� y'� �J CITY STATE ZIP / APN # p Land Use Application # BOS Dist �Locaxi on Code tN)NF*AGFBR—and/or SERVICE REOUESTOR BILLING PARTY Y DBA / �GIL`.UJS GN J IJ .Ci'S SDS PHONE #1 C. Ze I ' G_" O%.-(�z MAILING ADDRESS 1rLr'vl.. o,vi S7 n FAX # ( ) CITY iULIG TU(�' STATE C/4 ZIP Y S ZU BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHO hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. I also certify that I have pr r this applic i a that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance C s a StarKleTds, e F rel Laws. ;:ES EN, APPLICANT'S SIGNATURE Title• 21 Liz Date: 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 [MINTY 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: Assigned to 4=�7 �o•d�l`C (� Date Service Completed �` /� / Employee # b � a b Action Required: Y / N Service Code —2c'/�-/ Date PROGRAM ELEMENT Fee Amount Amount Paid Datel Payment Payment Type Receipt 4 # Recvd By rof �Check REHS _/_/ SUPV _/_/_ ACCT UNIT CLK _iJ