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SERVICE REQUEST = � C REQ) Revised 8/23/93 <br /> FACILITY TO N C1 D RECORD IDN INVOICE N 3L( f� f <br /> rACILIiY NAME BILLING PARTY N <br /> T 1� <br /> SITE ADDRESS , n <br /> CITY )I {� _ Clay ZIPS <br /> OWUR/OPERATOR le I _ BILLING PARTY Y / N <br /> DRA PHONE N1 <br /> ADDRESS + � Li-}y�c PHONE N2 t ) <br /> CITY a dL4E ' ' " STATE � t ZIP <br /> --APN N —lend Use Application N <br /> BOG at location Code <br /> CnHTPArInR nndlor ,/ �r <br /> SFRVICE RFOUESTOR S�<� BILLING PARTY Y / N <br /> ORA PHONE N1 f } <br /> NAILING ADDRESS © J d "AIR I I 7 e5 // �✓� FAX # { } <br /> CITY /C��� f�_ lSTATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that alt site and/or project specific <br /> Pus/EIID hm)rly charges associated with this facility or activity will be billed to the party identified es the BILLING PARTY on <br /> Page I of this form. <br /> I also certify that I have prepared this spptication and that the work to be performed will be done in accordance with all GAN <br /> JOAQUIN COUNTY Ordinance codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Titie. Date: <br /> AUTHORIZATION TO RELEASE 1NFORNATION! 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 retease of any and at( results, geotechnical data and/or <br /> environawntal/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It Is nvailabte and at the same time It Is provided to me or my repregentntive. <br /> Nature of Service Request: G Service Code <br /> Assigned to �i)ia � �l ,r d Employee ff ! r Date <br /> hate 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 /�/ .. UNIT CLK �/ / <br />