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v SERVICE REQUEST a (EN 00 61) Revised 8/23/93 <br />FACILITY ID '# <br />�� U� 2� O <br />RECORD ID # <br />MOM& <br />INVOICE # <br />Ll <br />`FACILITY NAME <br />SITE ADDRESS <br />CITY M,4AJ-f-e� CA ZIP Y'C� <br />OWNER/OPERATOR <br />DBA <br />ADDRESS <br />, <br />BILLING PARTY Y / N <br />BILLING PARTY <br />Amount Paid <br />Y <br />/ <br />N <br />PHONE #1 ( ) <br />Recvd By <br />PHONE #2 ( ) <br />CITY STATE ZIP <br />APN # P Land Use Application # BCS Dist Location Code <br />COLT ? and/or �� <br />SERVICE REOUESTOR SfCY M+-T���(Cp Z [3 Gr. BILLING PARTY Y N <br />DBA PHONE #1 <br />MAILING ADDRESS <br />FAX # (Z--dq)fCV_ 37 <br />CITY J%�aCA-�CM� STATE (:4 ZIP <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />DHS/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. n <br />I also certify that I <br />JOAQUIN COUNTY Ordi na <br />-and that the work to be performed will be done in accordance with all SAN <br />and Federal laws. '4"m E.N!p!-� <br />RE(c�.� N�pFY�i�� <br />APPLICANT'S IGNATURE — <br />MW <br />Title- Date: <br />SAN JUAUUIN CL-.JNi Y <br />PUBLI'_ HEALTH SEHViCE6 <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the own'aNY�B�NA>it®N•.bHF�ggFrii:DKSKbne, 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 # a6a <br />Further Action Required: Y / N <br />Service Code <br />Date 'S'/ / 7 I-ao— I <br />PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />_o <br />D <br />ISUPV �CLK <br />ENS <br />V <br />Y <br />