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_ <br /> SERVICE REQUEST Du,SERYREO) Revised 8/23/D393 <br /> 1 <br /> FACILITY ID R RECORD ID K 1 NVOICE R <br /> FACILITY NAME BILLING PARTY Y N <br /> �7 <br /> SITE ADDRESS <br /> CITY ! ^T�N CA ZIP <br /> WNER/OPERATOR BILLING PARTY <br /> DBA PHONE 01 <br /> ADDRESS PHONE K2 ( ) <br /> CITY STATE ZIP <br /> - -APN # Le Use Application M <br /> r F / BOS Dist Location Code <br /> T <br /> SFRVICEREOl1ESTOR //a�F—'T�I�t �i�t•—•Y/CGS JIf�I/0� BILLING PARTY Y / N <br /> DBA PHONE 01 (go 1 <br /> MAILING ADDRESS J \� ��`� FAX <br /> CITY STATE ZIP <br /> PILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site and/or project specific <br /> PHS/EHO hourly charges associated with this facility or activity will be billed to the party Identified so the BILLING PARTY on <br /> Pnqe 1 of this form. <br /> I ntso certify that I have prepared th alleation and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinanc C s a Ste rds, State a eral laws. <br /> APPLICANT'S SIGNATURE <br /> Title: 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 /> envirormental/site assessment Informatlon 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: 's N JC Service Code <br /> Assigned to le� �/uCfr�'IQ� Employee N Date p�\ <br /> Date Service Conpleted _/ / Further Action Required: Y / N PROGRAM ELEMENT J-h u <br /> t;ree Amount Amount Paid Date of Payment Payment Type Receipt / Check 0 Recvd By <br /> 3 <br /> RFHS / / SUPV _/_/_ ACCT -/_/_ UNIT CLK _/ /_ <br />