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SERVICE REQUEST L (5ERVREQ) Revised 5/13/93 <br /> FACILITY 1D # RECORD ID # BILLING PARTY Y J N <br /> Y \ 'fT <br /> FACILITY <br /> SITE ADDRESSL `7 <br /> CIT Yc ( 1 CA ZI �C'S # _L /U U <br /> OWNER OPERATOR fN�FiFN�-�f/+�/ BILLING PARTY 1-Y <br /> DBA PHONE #1 (-ZD i ) "s, <br /> ADDRESS A r� ' � PHONE #2 <br /> CIT STATE Z I P <br /> APN <br /> Census ---- BOS Dist Location Code City Code <br /> # �--- <br /> CONTRACTOR and/or <br /> SERVICE REQUESTORS'i�, lCi1�3�J =�-LFA ° JC f BILLING PARTYL�Y N <br /> DBA PHONE #1 <br /> MAILING ADDRESS / C�' 3a __ FAX <br /> CISTATE ZIP 7. �C1 +- <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 prepared this a liiccaatti-oonn.�and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and St nda State acid Federal laws. <br /> a <br /> APPLICANT'S SIGNATURE <br /> Title: Date: Fa - <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 time it is provided to me or my representative. <br /> Nature of Service Request: 3'� Oyu - y Service Code <br /> Assigned to Employee # Date / J <br /> Date Service Completed J I further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS / J SU PV _/ / ACCT �J UNIT CLK �/ / <br />