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SERVICE RE EST (SERVRED) Revised 5/13/93 <br /> FACILITY 10 # /'� RECORD ID <br /> /f # BILLING PARTY <br /> FACILITY NAME 1 t/`�/ �1 Q W <br /> SITE ADDRESS �(/fJ"(/ �� C <br /> 'IN <br /> CITY S76( .l D1J CA ZIP V # ri qg� ._ <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA ' PHONE #1 ( ) <br /> i <br /> ADDRESS i PHONE 92 ( ) <br /> CITY STATE ZIP <br /> APN # Census --------- BOS Dist Location Cade City Code ------ <br /> CONTRACTOR and/or ASC <br /> ./ W , <br /> SERVICE REDUESTOR A��� /J ,O&D <br /> V (— BILLING PART//Y__ <br /> DBA PHONE #1 ) � — <br /> MAILING ADDRESS !/ 1� �—/p.,��/`/J FAX # (�) - <br /> CITY I/V �14f,K_r l/Vf�N70 STATE N1 ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or1�p.-roject specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the party ident Y'rr�ai< I�a�i� ei [ING PARTY on <br /> Page 1 of this form. <br /> nn r.rnt <br /> I also certify that 1 have prepared this application and that the work to be performed will be doR�`iM act dance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. SAN JOAQU": • L;. '�1y <br /> PUBLIC HEA! i ItE:' ICES <br /> APPLICANT'S SIGNATURE ��-? � ENVIRONMENTAL r1EAL1 hi JMS'.Otd <br /> Title: Ilh L I U'r Date: ��✓ <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 /> envirormentaL/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: 'h / _47 T/ e' <br /> ; Z9 Service Code l9 <br /> Assigned to C` Employee # 2` � Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT a. ! �6 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> -� r / 3 3 <br /> REHS _/ /_ SUPV _/_/_ ACCT _/_/_ UNIT CLK _/_/_ <br />