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I SERVICE REQUEST <br />\. )._ 3 -- R a)Revised 8/23/TS <br />TAf, 11 I1Y ID N RECORD ID A aN ICE N <br />riiilNe irARFY r i <br />rACIIATY NAME <br />00 <br />SITE ADDRESS 11.0 a,? A -Z Bo g- P -b <br />CITY TO y1 CA zip g,5 2 L)3 <br />OWNFR/OPERATOR <br />DBA <br />ADDRESS <br />CITY <br />i-ArN N = <br />STATE <br />Use Application N = <br />ZIP <br />BILLING PARTY Y / <br />PHONE Al ( ) <br />PHONE N2 ( ) <br />ROS Diet Location Code <br />FDNTPACTOR PM/or <br />sFRVICE REDUESTOR 1 &4 �� i J� Urt�Lf�G1 l�Q �✓I BILLING PARTY Y / N <br />DBA PHONE N) [ ) - <br />MAILING ADDRESS J-Gq [/ <br />le <br />i <br />CITY �-L �� STATE �(� ZIP <br />PILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that Zito and/or project specific <br />Pus/END hmrrly charges associated with this facility or activity will be billed to the party Idenj�LING PARTY on <br />Page 1 of this form. <br />MAv CEI QED <br />I also certify that I have prepared this application and that the work to be performed wl �l$� AIn a�or�e with all SAN <br />JnADUIN COUNTY Ordinance Codes and Standards, .Sttaattie and Federal laws. fNVIjoRQNMF� � SEOuNry <br />RV <br />' <br />APPLICANT'S SIGNATURE 4-_h ! �UikIRl17j� <br />X <br />Title: /\ C !'z Q Dete: <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, t, 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 dote and/or <br />environmental/site assessment information to SAN JOAOUIN 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 /Rewest: 10`�'}/��-- L%�"'SU K-�'I Service Code <br />R4 <br />Assigned to l I ![.''.0 (/l U Employee N � `'t' <br />� -Z� Date / / <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z 3 , 5:-Q <br />// <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt N <br />Check N <br />Recvd By <br />A <br />RFHS I SUPV _/_/_ ACCT - _/_ / UNIT CLK <br />