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SERVICE REQUEST (SERVREO) Revised 8/23/93 <br /> jt,(:ILITY ID N <br /> I <br /> RECORD ID N INVOICE N EN <br /> rAr.ILITY NAME —AXScgiLLINO PARTY <br /> SITE ADDRESS �5 <br /> .-?—C3 / n <br /> CITYr� CA ZIPj7 <br /> OWNFR/OPERATORPILLING PARTY Y / N <br /> DBA PHONE Mi ( ) <br /> ADDRESS i �..J�`� PHONE M2 ( ) <br /> CITY STATE ZIP <br /> —APN M Lend Use Application N <br /> 805 Dist Location Code <br /> CONTRAC0 and/or C� �^_ _ ��, <br /> TCE REOUESTORSTY"J BILLING PARTY Y / (X <br /> DBA��'3 ,( /�+ / ,,` PHONE N1 ( ) <br /> MAILING ADDRESS 7��5aa ��7�j1�� / "6 ^�n�"' FAX 0 <br /> CITY Q�6C�� STATEZIP <br /> • PILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent'of same, acknowledge that ell site and/or project specific <br /> PHS/EHO hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> Page t of this form. <br /> I also certify that IVhav p"r" ja application and that the work to be performed will be done in�acfc�l�a�Ge:with all SAN <br /> JOAOUIN COUNTY Ordinance s a tenderds, State and Federal laws. "° RFr.pp%rr-7 <br /> APPLICANT'S SIGNATURE _ - <br /> �- o—// (r SAN JOAQU!NCV,Ni <br /> Title: Date: 7 I HEAE TH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIOn• <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 date and/or <br /> environmental/site assessment Information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon es <br /> It Is available and at the some time It is provided to me or my representative. <br /> Nnture of Service R1egquuesttj:n I \ Q I n Service Code <br /> Assigned to )C .1 11 l/1 ) Employee M 6 1Y� Date <br /> Date Service Completed ` /�/ ` y� Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> NIT CLK <br /> RENS _/_/ SUPV _/ /_ ACCT <br /> r <br />