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y SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # ` RECORD ID # INVOICE # <br /> FACILITY NAME BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY <br /> n CA 21P <br /> OWNER/OPERATOR Ye BILLING PARTY Y / N <br /> DBA l \t�n'b^ \ _ PHONE #1 <br /> ADDRESS ^ `^ (-"1 `� �'Ln�'Q \ PHONE #2 ( ) <br /> CITY .�"'[[>�J STATE ZIP <br /> APN # Land Use Application # <br /> SOS Dist Location Code <br /> CONTRACTOR and/or ` T ��1 - BILLING PARTY Y / N <br /> SERVICE REQUESTOR -'CP. <br /> DBA PHONE #1 <br /> MAILING ADDRESS / n�,S1-6�L�Q- FAX # ((*6 )ZtQ <br /> CITY STATE z 1 P 90-2Q' )i^ _ <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, 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 that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. PAYMENT <br /> is F l`F IlFt't'! <br /> APPLICANT'S SIGNATURE <br /> Title: Date: .'I!NTV <br /> PUBLIC;HEALTH SERVICES <br /> AUTHOR17ATION TO RELEASE INFORMATION: In addition to the above, when applicab4NVJIRA%4J?K 4L 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: Service Code jft�4 — <br /> Assigned to 1 1 Employee # Date / <br /> Date Service Completed / / '9� Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPV *Vmr- ACCT / We- I UNIT CLK _/�_ <br />