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+ • SERVICE REQUEST (SERVREQ) Revised 8/23/43 <br /> FACILITY ID N <br /> RECORD ID N INVOICE N <br /> C <br /> FACILITY NAME ���cOLi �ao�S BILLING PARTY Y / N <br /> /�� <br /> SITE ADDRESS Y'�S'+�� p� I'�bIEir -1_1 c� <br /> CITY CsTOUE-aq CA ZIP�J6� <br /> BILLING PARTY Y / M <br /> WNFR/OPERATOR <br /> DBA PHONE N1 ( ) <br /> ADDRESS PHONE 02 ( ) <br /> CITY STATE ZIP <br /> -APN N (=Land Use Application N <br /> IBOS Dist Location Code <br /> CONTRA /or 1�' c T�� <br /> SERVIfE REQUESTOR STOCK` ''y ` IFNQ 2>174 --{�G ` BILLING PARTY Y / N—� <br /> DBA PHONE Nl 670 C7 ) t ' <br /> NAILING ADDRESS � n1'V� FAX N (Zd )7b7 <br /> CIiYL�--''`� STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be bitted to the party Identified as the BILLING PARTY on <br /> Pnge 1 of this form. <br /> I niso certify that I tpr this application end that the work to be performed will be done In accordance with all SAN <br /> JOAQUIN COUNTY OrdlnaStandards, State and Federal laws. <br /> SP�APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AIIIHORIZA710H 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 ell 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 sash! time It Is provided to me or my representative. <br /> Nature of Service Request: <br /> Service Code <br /> Assigned to Employee N Date _/ / <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> RENS _/_/_ SUPV _/_/_ ACCT _ <br />