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SERVICE REQUEST (SERVREO) Revised 5/13/93 <br /> FACILITY ID # RECORD ID # BILLING PARTY / N <br /> FACILITY NAME <br /> SITE ADDRESS ; y + �} <br /> CITY c� CC�'�[].`y CA ZIPS I FAC TT - <br /> OWNER/OPERATOR I "_ BILLING PARTY N <br /> DBA PHONE #1 C9 � <br /> ADDRESS 3067 a>i21D/J,4A 6 /4,4C, PHONE #2 <br /> CITY rI STATE ZIP <br /> APN # Census ------- BCS Dist Location Code City Code <br /> rte.. <br /> CONIRACTOR and/or {, <br /> SERVICE REOUESTORTU �T73 � %C7r17"iC� BILLING PARTY Y / FI <br /> DBA PHONE 41 <br /> MAILING ADDRESS �+=C�- 1� FAX # (-'y C ) ex q- �( <br /> C[TY <br /> G TS,{-� STATE ZIP - (L' <br /> J <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I haye prepared t i application and that the work to be performed will be done in accordance with all SAN <br /> a <br /> JOAQUIN COUNTY Ord inanc F d� ta and federaL laws. <br /> APPLICANT'S SIGNATURE <br /> Ti tle: l .S 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 authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment inforW,"4,oeri-r6'-?W-1111 Y PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> �Y <br /> it is available and at the a time it is provided to m resentative. <br /> Nature of ServiceR t: Service Code L` <br /> Assigned to rtp oyee Date <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 /> E <br /> _/ / SUPV �/ / ACCT f / / UNIT CCK _/ / <br />