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SERVICE REQUEST ' t ) 8/23/93 <br /> FACILITY ID # RECORD ID # r 77 <br /> FACILITY NAMEq 0 � $1 LL ;NG PARTY � Y / N <br /> SITE ADDRESS 15f2 S } f <br /> CITY 0,6aA 2 CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE 101 <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or _ <br /> SERVICE REQUESTOR 1�L BILLING PARTY Y / N <br /> DBAoo�� PHONE #1 { D ) -o <br /> s� <br /> MAILING ADDRESS o�2 0 e t FAX # ( ) <br /> CITY -(C) _ STATE Ca ZIP t 7 3 5 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PIIS/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 application and that the work to be performed will be dome in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards S qd-Federal laws. <br /> APPLICANT'S SIGNATURE : <br /> Title: Date-_r <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 data arid/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 r/epresentative. <br /> Nature of Service Request: Service Code <br /> Assigned to Employee # Date --/- /-�/ G L <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 /> 4 / <br /> REHS �/ / SUPV /�� ACCT UNIT CLK _/� <br />