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. SERVICE REQUEST <br /> • (SERVREO) Revised 5/13/43 <br /> FACILITY ID # (Cq,C - ,1� ` �REt�CORD ID'v BILLING PARTY � / N <br /> \11 <br /> FACILITY NAME l.O����`vL AI�rAL l/'�I".OK.!]L��u�G'v D t�n��I4S �o `t <br /> TI <br /> SITE ADDRESS <br /> C,Sofa/,S�+I /,f�'tgM,' SrkfkNTL1�. � /� JIJ���p <br /> CITY JIV�-��-lVl'1 CA ZIP gg�yo AIN 0 9 1995 <br /> A/ eery h TNv C; Q 17c7C/ <br /> m <br /> OWNER/OPERATOR L, r1" I)kI— arki �� - �E Toww( ES Y / N <br /> DBA PHONE #1 <br /> ADDRESS r0-r 'rAM ©i�f/ / r- <br /> PHONE #2 <br /> / -4$ <br /> 1 ( ) <br /> CITY �l(sL1�-�V7"W STATE lA ZIP I $ y 10 <br /> APN # Census --------- BOB Dist Location Code City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR JGiy`�`� BILLING PARTY Y /// N <br /> DBA PHONE #1 ( ���! ) )71�( - <br /> �] O <br /> MAILING ADDRESS f�Zly'I,7 ,J� � A J`n�./,�- J� FAX # (ZO <br /> CITY �I�l01347 F(� STATE to ZIP q!;77-Cl <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/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 I have pr red this application and that the work to be performed will be done iRpo,dA" ith all SAN <br /> JOAQUIN COUNTY Ordinanc L s and Standards, State and Federal laws. jUN 1995 <br /> APPLICANT'S SIGNATURE <br /> p: ✓�`� <br /> Title: ufk�cu� A�/�Ll7Ff _ (G _ PUBLIC HEALTH SEHVICt <br /> Date: <br /> L HEALTH DIVISION <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 JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same <br /> -ftime it is provided to me or my representative. <br /> Nature of service Request: 1 Uull� �r"T'S�'.(Ci.l Service Code <br /> Assigned to yosl,��v�-S c... Enployeeqi�oa Date �f-) C <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount AmountPaidDate of Payment Payment Type Receipt # Check # Recvd By <br /> = <br /> REHS SUPV I _/_/_ ACLS / /� UNIT CLK <br /> t <br />