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SERVICE REQUEST (EN 00 61) Revised 8/23/93 <br /> CORD 10 M p 3 3f q O # <br /> ALI <br /> J/ <br /> FACILITY NAME LY''u^'ul`'r� }�"t"-e'/l/ BILLING PARTY Y / N <br /> � <br /> SITE ADDRESS ZDDL L> r — tk �� c <br /> CITY ['� I CA ZIP �(0(1:.1 <br /> OWNER/OPERATOR _ �/? �^ BILLING PARTY Y / N <br /> DBA PHONE #1 <br /> ADDRESS PHONE #2 O <br /> CITY STATE 71P <br /> APM # p Land Use Application # <br /> IBOS Dlst Location Lode <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR SGMIJV BILLING PARTY ��''''JJ f(//Y // N <br /> DBA r\ PHONE #1 ( ) !Ss <br /> MAILING ADDRESS �'/aA ^�` p(,Iy 5, `� � <br /> FAX # ( <br /> L <br /> CITY /" Iad✓ 'I.V STATE lAk ZIP [ 5Zs <br /> BILLING ACKNOWLEDGEMENT: I, 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. ' 'yA4EIVT <br /> _'jS�`'ft�'al l SAN <br /> I also certify that' I have pre ared this application and that the work to be dance performed will be done in accorn <br /> JOAQUIN COUNTY Ordinance a Ste ards, State and Federal laws. OCT 14-1997 <br /> APPLICANT'S SIGNATURE SAN J NTY <br /> ENVIRON�O HEALTH <br /> SERO ES <br /> W- TA HEALTH DIVlSlcm <br /> Title: � ' Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when apFdicable, 1, the owner, operator or agent of sane, of <br /> the property located at the above site address hereby authorize the relennse 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 saw time it is provided to me or my representative. <br /> Nature of Service RegTe <br /> st: �A,, p� Service Code S C O 3 ' <br /> Assigned to _ y�=�'a/ �+ Employee # Z 9 7-3 Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT _ <br /> Fee Amount Amount Paid Date of Payinent Payment T pe Receipt # Check # Recvd By <br /> PENS / / SUPV 4"f�/ ��! / ` ACCT �_/_/_,_''"OOONIT CLK _!_/_ <br />