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SERVICE RECUEST �31( ERc <br /> V2E0) Revised 5/13/93 <br /> FACILITY ID # p1t11 RECORD ID #' BILLING PARTY Y f N <br /> it r xD - S5 3 FACILITY NAME l .�� �` /f t �' © 1 ,r I ciqty <br /> SITE ADDRESS . ! / /<?O �_.`I Q <br /> CITY L�.IT ACV'` CA ZIP <br /> OPERATOR BILLING PARTY ly- <br /> f N <br /> ==J <br /> DBA PHONE #1 <br /> ADDRESS / � �_ q-e , ,� G PHONE #2 <br /> CITY C ��LA STATE ZIP <br /> APN # Census -- BOS Dist Location Code City Code - ---- <br /> CONTRAC�Yid/or <br /> SERVICE REDUESTOR Gam' � � BILLING PARTY Y / N <br /> DSA PHONE #1 <br /> MAILING ADDRESS' I`� `' `F FAX # <br /> CITYe' - Cif t 'STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHD 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 1 have re ed this application dnd that the work to be performed wilt be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance C s- � S ndards, State and Federal laws. <br /> APPLICANT'S SIGNATURE `�� <br /> � r <br /> Title• Date: <br /> AUTHORIZATION 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 /> environmental/site assessment information to SAN JOA©UIN 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 /> 5 <br /> Nature of Service Request: <br /> �,. .e. service Code <br /> Assigned to ( .f _Q K; Employee # Li'1� 0 Date <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 /> SUPV _/ / ACCT _/ UNIT CLK <br /> 7 <br />