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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> =FACILITY # RECORD ID # INVOICE # <br /> FACILITY NAME -S,PjY J 2— <br /> OR t. 4CQ/li <br /> .. n `�dqr BILLING PARTY Y / Np <br /> SITE ADDRESS y <br /> CITY SfOC//'JI�iJ CA ZIP J-`-�'a C) 'v <br /> OWNER/OPERATOR i9/1J 44 th) y-LI• `j J-- %-�t jM BILLING PARTY <br /> DBA ��/,/�Uq PHONE #i <br /> ADDRESS / / �' /" S /7 /" PHONE 02 ( ) <br /> CITY J�OC �ol� STATE �_ ZIP <br /> 9s ;z� <br /> APM # Lard Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR � ✓/ '�I"Y 1 1 ._-J BILLING PARTY Y / N <br /> DBA S/� MF PHONE #1 <br /> MAILING ADDRESS �JpC9 FA% <br /> CITY A�n� STATE ZIP <br /> ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ail 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. PAYMENT <br /> I also certify that 1 have prepared this application and that the work to be performed will be done inRMfq AWh all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> JUL 81997 <br /> APPLICANT'S SIGNATURE <br /> ✓ � SAN JOAQUIN <br /> Title: PUBUC HEALTH SERVICES ` <br /> r--f,.) Date: I fuiq[�IulEl FTAL HEALTH DIVISION <br /> - <br /> AUIIIOIIZATION TO RELEASE INFORMATION: In addition to the above, when nppticnble, 1, the owner, operator or agent of some, 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. (/ 1 <br /> Nature of Service ReQlest: CL nN <br /> Service Code © J— <br /> Assigned to �» Y� Employee # l�3 Date 3_/_�/ <br /> 9 /, <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT 2%_3 C)Y <br /> Fee Amount Amount Paid /Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPV / / ACCT -/ '� /_/� UNIT CLK _/_/— <br />