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•� �r SERVICE REQUEST (SERVREG) Revised 8/23/73 <br /> fACILITY ID N I RECORD ID # INVOICE # C1(�_ <br /> rACILIIY NAME &L-'-ZAJs- �fIl item is; BILLING PARTY Y / N <br /> SITE ADDRESS �4-7ab <br /> CITY Tam,.. CA zip %-37L- <br /> nWHFR/OPERATOR S 39n..Q BILLING PARTY Y / N <br /> DBA PHONE #1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> 1APN # n r� p Lard Use Applicatl on N <br /> - — 11 BOS Dist Location Code <br /> CONTP,ACTOR and/or <br /> SFRVICF REG(IESTOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS FAX R ( ) <br /> CITY STATE ZIP <br /> FILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PIS/END hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done In accordance with all SAN <br /> JOAaIIN COUNTY ordinance Codes snd(( Standard/s, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Le� cTr- Date: <br /> --N"".bZ,,,,;v�'i Ef--, � VYk ru„� "Y , <br /> r,i <br /> AI11HORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 /> cnvirormental/site assessment infortantlon to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time <br /> _”it is provided to me or my representative. <br /> Nature of Service Request: Service Code ip L <br /> �A r _ <br /> assigned to � . I"�en-� s Employee # �"l� Date -31 I t 1 JJ �-� <br /> Date Service Completed Further Further Action Required: Y PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> 47 <br /> am <br /> s <br /> SUPV _/__/ ACCT g /�/ UNIT CLK _/ /_ <br />