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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> 5 <br /> FACILITY ID # RECORD ID # <br /> FACILITY NAME ✓e n BILLING PARTY <br /> SITE ADDRESS <br /> CITY C�k ILn C -A CIS 2G, ZIP <br /> OWNER/OPERATOR n �1`��C", BILLING PARTY 0 / N <br /> DBA PHONE #1 <br /> ADDRESS {/�� 7� �- I L/]1-C. <l 10 . PHONE #2 ( ) <br /> CITY ' `�C�C '�Cn STATE ZIP `7 l <br /> ppN # p Land Use Application # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or `i h L,n <br /> SERVICE REQUESTOR ��\� / ✓ nUlrU n/l'\2 Y11znl ' BILLING PARTY 71, <br /> DBA PHONE #1 (70`/ 15 47 - �lO c�U <br /> MAILING ADDRESS f��� �Ux `7 0 FAX # (2--cy ) Sy 7 - <br /> CITY 5f��. k Iy STATE CA zip ( S2a <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 /> I also certify that I have prepared this application and tha the work to be performed wiLL be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes a Standards, S edera laws. <br /> APPLICANT'S SIGNATURE <br /> (/, <br /> / l <br /> Title: l! Ct PtL(' Vl/fii� Date: Ina r <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 /> Nature of Service Request: 42 46;;; — Service Code <br /> t <br /> Assigned to Employee # 1 l U� Date -2— <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT �--3 . <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 3 <br /> REHS /_/ SUPV _/_/_ ACCT ^/_,_/_` _ UNIT CLK <br /> v V � <br />