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SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> FACILITY ID # �j- RECORD ID # _ - , �-' <br /> INVOICE 0 <br /> • raf.ILItY WAKENe— <br /> SITE ADDRESS lit-fjG IEr-1-c�14Ps <br /> CITY CA ZIP�— <br /> OWNFR/OPERATOR BILLING PARTY Y <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> ._APN-# ;/or p Lend Use Application # <br /> IBOS Diat Locet ion Code <br /> CONTRA <br /> SERVICE <br /> DBA /�� ,( PHONE #1 (�G 7 )4i _- <br /> MAILING ADDRESS 6 u`� r� FAX # �(_ MK' - R3y <br /> CITY �fC'�-1�-- � STATE � ZIP �7 J Gam' r <br /> • BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PIIS/FHD hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> rsge 1 of this form. <br /> I nlso certify that I h Lreds application and that the work to be performed will be done in,Accordance with all SAN <br /> JOAQUIN COUNTY Ordinanc odards, State and Federal laws.cNOU 2 2APPLICANT' -. <br /> 7 PUBLIC HEALTH S�RVIur- <br /> Title: Date: �NVIR(IUUENTaI HEALTH DO' '.: <br /> AUIHORIZATION 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 D VISION as sooq ea <br /> it Is available and at the same time It is provided to me or m' representative. <br /> Nature of ServiMR, e,ti Service Code <br /> oxk <br /> ASSigned to Employee # C) t t0 Date —L�_/ Z U / <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 /> RFHS I _/ /_ SUr° / /_ ACCT _/_/ UNIT CLK <br /> � f <br />