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Iti� � <br /> SERVICE REQUEST (jnk (EH 00 61) Revised 8/23/43 <br /> FACILITY ID # <br /> INVOICE <br /> # <br /> BILLING PARTY Y- <br /> FACILITY NAME <br /> SITE ADDRESS `•��� I �� <br /> CITY QG CA ZIP- 61'5Z04 <br /> pBILLING PARTY Y / N <br /> OWNER/OPERATOR may' - �` <br /> DBA 'bre PHONE #1 ( 9 (a )��- $26A <br /> PHONE #2 <br /> ADDRESS <br /> CITY —(7011' +ver STATE CA ZIP <br /> APH # Lend Use Application # <br /> F67o71tE7::Loc.ti,- <br /> BILLING PARTY Y <br /> SL3V10E REQUESTDR S h i 'n` artiNfa / <br /> DBA U` PHONE #1 <br /> �VGS 1UG <br /> MAILING ADDRESS O.f E*'4 FAX # <br /> _ , <br /> CITY aG�3 Klu°+Ni 0 STATE ZIP 1,5&25 <br /> BILLING ACKNCWLEDGEMENT: 1, 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 /> 1 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 /> 01 APR <br /> APPLICANT'S SIGNATURE <br /> Title r{t' lgn� $l1Date— <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 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 /> Service CodeC )]-- <br /> Nature of Service Request: q p� <br /> Date <br /> Assigned to <br /> Employee # <br /> Further Action Required: PROGRAM ELEMENT <br /> Date service Completed / - <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # <br /> Check # Recvd By <br /> �✓ SUPV / / ACCT' /- / UNIT CLK /— <br /> REHS <br />