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.,� SERVICE REQUEST ( 03 <br /> FINVOrAf.I LITY ID N ,] l�0 RECORD ID N �j�oS 5 r- <br /> ICE N <br /> /1 2��'asi 810 FA <br /> fAG tI ITV NAME e�l BILLING PARTY Y / <br /> IN ! <br /> SITE ADDRESS -,, ^,� .. <br /> CITY w` v-V! , _ CA ZIP K <br /> e?s i.� � � F (c-> <br /> IV /ODPERATOR ((T L feel I 1N/ BILLING PARTY Y �;�/�lN <br /> ORA TA nfnnrftAn� • I ' `�4gPti PHONE N1 (S�)g21 '�.I <br /> ADDRESS cc L.� �PHONE N2 ( ) <br /> CITY &Vo RO/"t C9/� STATE �� ZIP M< <br /> FAPN Al (Lend Une Appl Icat I on N - <br /> c - — II � BOS Dist Locet ion Code <br /> CONTRACTOR raid/or <br /> SFRVIr,E REOUESTOR I1) nem BILLING PARTT Y / l� <br /> DBA �7r-/� '_/L //.' PHONE 01 ( /to )4ky - 2i2 <br /> MAKING ADDRESS �f �lJ 7�ULVIJ,(f� �LN � rN( N <br /> CITY S /I Gtrn N f/ STATE _ ZIP � L, <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or event of same, acknowledge that all site and/or project specific <br /> PHS/EHO hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> Pnge 1 of this form. <br /> I nlso certify that I have prepared this application and that the work to be performed will be dotty! In accordance with sit SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, <br /> State and Federal laws. <br /> APPLICANT'S SIGNATURE : c_L�— <br /> � <br /> Title: ;- —,,Q� Date: C) (`�14 <br /> •. �f #� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the outer, operator or agent of acme, of <br /> the property located at the above site address hereby authorlte the relenee of any and ell remits, geotechnical date ardor <br /> mvirtxmental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION es soon as <br /> It Is available and at the same time It is provided to me or my representative. <br /> Nature of Service Regxst: C Service Code <br /> pI <br /> Assigned to L,T 130 m / S Employee N 0Oz) O/ Date <br /> Date Service Completed / /� Further Action Required: Y. / N PROGRAM ELEMENT c `1 <br /> fee Amount Amount Pald Date of Payment Payment Type Recelpt N Check N Recvd By <br /> i RENS _/_�_/ �SUPV _/_/_ ACCTp�/�_/� UNIT CLK �_/ /_ <br />