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SERVICE REQUEST <br />FACILITY ID N RECORD ID M INVOICE N <br />FACILITY NAME <br />SITE ADDRESS <br />CITY <br />OWNER/OPERATOR <br />DBA <br />ADDRESS <br />CITY <br />P APN N = <br />CONTRACTOR and/or <br />SERVICE REQUESTOR <br />DBA <br />MAILING ADDRESS _ <br />CITY <br />CA ZIP <br />STATE <br />Land Use Appll cat i on N = <br />ZIP <br />STATE ZIP <br />(EH 00 61) Revised 8/23/93 <br />BILLING PARTY Y / N <br />BILLING PARTY Y / N <br />PHONE N1 ( ) <br />PHONE N2 ( ) <br />BOS Dist Location Code <br />BILLING PARTY Y / N <br />PHONE N1 ( ) <br />FAX N ( ) <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific <br />PHS/END 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 ell SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br />APPLICANT'S SIGNATURE <br />Title: <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 />Assigned to <br />Date Service Completed / / <br />Employee N <br />Service Code <br />Date _/ / <br />Further Action Required: Y / N I PROGRAM ELEMENT <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br />REIIS // SUPV _// ACCT _// UNIT CLK _// <br />