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SERVICE REQUEST • " � (SERVREG) Revised 8/23/03 <br /> FACILITY ID M <br /> RECORD Ib <br /> FACILITY NAMe C�11 Iu 4tA4 l�� f�ti� N4 pe -Y_i w <br /> ' 511E ADD <br /> BESS /t �' 0 I <br /> QAC(t (ti cA z I P��=J 3 / <br /> i IAIRrR/OrEPA IOk BILLING PARTY Y / N <br /> f' <br /> DBA PHONE M1 ( ) <br /> ADDRESS PROPS M2 ( ) <br /> i <br /> t. city STATE 21P• <br /> r _APR <br /> 6---- Lend Use Application k <br /> /�' B05 Dlat LocationCode <br /> r,. SERVICE FRt nrd/or a �. (1 ,( <br /> L <br /> SERVICE REOVESIOR 6yU BILLING PARTY Y / N <br /> DPA __. PHONE M) <br /> NAILING ADDRESS (-9403 (d"`' - Y "� FAX B ( ) <br /> t CITY �o STATE _ 21P <br /> i <br /> nil-LINO ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of acme, acknowledge that all site and/or project apeelfll <br /> i' PRS/END hourly charges associated with this facility or activity will be billed to the party Identlfled a the BILLING PARTY on <br /> Page'1 of this form. <br /> I nlso certlfy that i have prepared this application and that the work to be performed will be Clone In accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and federal laws. <br /> i APPLICANT'S SIGNATURE ! <br /> Title! bete! <br /> AtIIIIORiZATION 10 RELEASE INFORMATIORI In sdiltlon to the above, when applicable, 1, the owner, operator or agent of same, of'' <br /> i. <br /> the property located at the above site address hereby authorize the release of any Ord all results, geotechnical date ard/or ," <br /> mvlrormental/aIle assessment Information to SAN JOACUIN CUUN4 PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as Boon as <br /> It la available and at the same time It In provided to me or my representative. <br /> Nature of Service RecTuestt 6 /u-'' K � Service Code <br /> Assigned to 4 / ICA Employee 0 0 414?, Date <br /> Date Service Completed _/ / Further Action Required! Y / N• PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment type Receipt M Check IS �n Recvd By <br /> . 3 � D <br /> ar NS— _/_/ UMt - _/ /_ J ACCT / / UNIP'CLK `/ J <br />