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,n (nl r111A/?'�;r� <br /> SERVICE REQUEST (SERVREQ) Revised 5/13/93 <br /> FACILITY ID # RECORD ID # BILLING PARTY Y / <br /> �7 <br /> FACILITY NAME �{'�D (/L /� �k)V�-�7W✓1��'Y <br /> SITE ADDRESS <br /> CITY ' Oe-l•�'I7T/'� rI- CA ZLP 9S ZOO <br /> OWNER/OPERATOR _ f DU- or IV`I l `P,O1e r BILLING PARTY <br /> DBA )��77 / /I- y PHONE #1 (�)2;1- 1 37 7 <br /> ADDRESS 1000 L4, , U1V4 t4lyl'L( -! , p �P�HONE #2 (�) !-/3 - 7L)j <br /> CITY �'(�L1�-( �� STATE Lft 21P 751 -' <br /> APN # Census --------- BOS Dist Location Code City Code T=1 <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR 7�M C.b BILLING PARTY <br /> DBA // II''•• C PHONE #1 (..., ) SZv -�_ <br /> MAILING ADDRESS ty 1 �7 . �'"1'T�i S4, FAX # ( CFS f ) S�'t <br /> CITY Mode) Iy STATE ZIP 7S <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge tht*,It LL�site and/or project specific <br /> PHS/E HD hourly charges associated with this facility or activity will be billed to the party„ldf fT11eihe BILLING PARTY on <br /> Page 1 of this form. J� C4.F/�4�h- f <br /> JAN Cry It. <br /> 1 also certify that I have prepared this application and that the work to be performed•5A* 2c done�7n ;1095dance with all SAN <br /> JOAOUIN COUNTY Ordinance Codes and Standlardrs/, -State and Federal laws. l��/ISI:(I,,` Q I <br /> Ili-A <br /> cloutv <br /> APPLICANT'S SIGNATURE <br /> V [/l C ,�•- ENVI t�,�M N HEALr ��S <br /> Title: ���"" , /�iL.Lt..Y� , 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 of any and all results, geotechnical data and/or <br /> environmental/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. <br /> Nature of Service Request: <br /> Reequ�est�:' , Service Code <br /> Assigned to —Tf�-S — mployee # Date __L/_�/ � <br /> VV VV <br /> 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 /> REHS _/ /_ SUPV _/_/_ ACCT _/ UNIT CLK 7=7 <br />