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1 SERV <br /> E REQUEST.REQUEST' .'�c1`J3G'c. (EH 00 61) Revised 8/23/93 <br /> FACILITY ID #!- RECORD ID # �T/1� INVOICE # <br /> FACILITY NAME <br /> SITE ADDRESS Li `� I I" Vol <br /> I� <br /> n <br /> CITY.�I /^(� �.i�✓�'"� '" CA�IP <br /> OWNER/OPERATOR j'>V ll ✓ l" / I l BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # p Land Use Application # <br /> IBOS Dist Location Code <br /> CONTRAC <br /> SERVICETRDUESTOR �T.J �' �-'�^- � ' `� v ' BILLING PARTY Y / N <br /> �1 l <br /> 1/ <br /> DBA II ��'�yq ��/�qq•' PHONE #1 ( V )_ <br /> E& 11�71j <br /> MAILING ADDRESS Iw `-�' I IJI " d FX�'AAX.�I# ( ) <br /> /�' �-i� I <br /> CITY �f /I ✓I I � y� gTATE�� ZIP () <br /> BILLING ACKNOWLEDGEMENT: 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 a//nd Standards, State and Federal laws. <br /> ��11���n111 `7 <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHOR12ATION 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.knLnA //,, <br /> Nature of Service Request: 1,. L. <br /> _I(9y� Service Code <br /> Assigned to �' Employee # `�I / '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 /> / <br /> —lot 1 0�, Ji <br /> RENS./ _ SUPV _ _/_ ACCT - _/_/,mss ITT CLK _/ /_ <br />