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SERVICE REQUEST .—. (SERVREO Rev sed 8/23/93 <br /> FACILITY ID / ��1 RECORD TO R INVOICE N - - ----- - <br /> rAr.ILIIY NAME �' � � 'n�"T " BILLINg PARTY <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> (YWMr R/OPERATOR RILLING PARTY I Y / N <br /> DBA <br /> PHONE M) (- <br /> ADDRESS ) - <br /> PHONE N2 ( ) - <br /> CITY STATE ZIP <br /> -ArN N pLend Use Appli cat IW M <br /> IROS Diet Location Code <br /> CONtRACTOR nsd/or BI(LINC PARTY Y / M <br /> SERVICE REOUESTOR <br /> DBA PHONE M1 ( ) <br /> NAILING ADDRESS FAX 0 ( ) <br /> CITY STATE ZIP <br /> RILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of Hsme, acknowledge that ell Hite end/or project epxclflc <br /> PRS/END hourly charges associated with this facility or activity will be billed to the party Identified an the BILLING PARTY on <br /> PHge' I of this form. <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 /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 authorlte the release of any and all results, geotechnical data and/or <br /> mvironmental/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 me or my representative. 2 <br /> Nature of Service Request: � Service Code <br /> Assigned to .G / �_ Employee M t�d0 0 Date <br /> Date Service CoMteted _/ J / Further Action Required! Y / N PROGRAM ELEMENT �✓"� <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt R Check 0 Recvd By <br /> I 1 <br /> RFNS I _/_f_I SUPV _/__/_ I ACCT _/ /_ UNI TL <br />