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8 <br /> SERVICE REQUEST (EN 00 61) Revised 8/23/93 <br /> FACILITY ID J RECORD ID # INVOICE # <br /> FACILITY NAME / <br /> BILLING PARTY <br /> SITE ADDRESS <br /> CITY C CA ZIPw 7� G <br /> OWNER/OPERATOR S'/j�f►J BILLING PARTY <br /> DBA PHONE #1 <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> FAPN # p Land Use Application # <br /> II Bos Dist Location Code <br /> CONTRACTOR and/or �J-- <br /> SERVICE REQUESTOR BILLING PARTY / N <br /> DBA ` t ` t I PHONE #1 (' ) <br /> MAILING ADDRESS v/� Yt FAX # <br /> i <br /> CITY1/ STATE<J�j ZIP <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 the9.VllNli PARTY on <br /> Page 1 of this form. QQppf/?� ``���V!! <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in acfdl'UU�c� a ®AN <br /> JOAQUIN COUNTY Ordinance Codes and <br /> �Staanndd ds, State and Federe laws. V /99 <br /> APPLICANT'S SIGNATURE e�VI�NA'lf/y F�TI��nU�y <br /> TAL SF } ry <br /> Title: Y— C) Dater <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: Service Code n Y— <br /> Assigned to a�--(J�.QT\�[, -h Employee # Date — (4—/ 3 Q / <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> -2-3 X34 - ✓ g(-qa Lu <br /> RENS /�/ 'Cy SUPV _/ /_ ACCT _/_/_ UNIT CLK _/ /_ <br />