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SERVICE REQUEST (SERVREQ) Revised 5/13/93 <br /> BILLING PARTY Y / N~ <br /> FACILITY ID # RECORD iD # <br /> FACILITY NAME <br /> SITE ADDRESS ! i KX) "" VIP,) L <br /> CITY CA ZIP f. 3 <br /> OWNEMPERATOR <br /> PHONE #1 <br /> DBA <br /> tj q PHONE #Z (ci`1Q)e,7/c5-- <br /> ADDRESS <br /> CITY STATE r ZIP <br /> � f Location Code City Code ------ <br /> APN N 2u 7 I —no� — 1 r Census -- BpS Dist <br /> CONTRACTOR and/or BILLING PARTY Y / N <br /> SERVICE REQUESTOR1LX� <br /> PHONE #1 ('51 Q - � <br /> DBA <br /> FAX # (510 ),9W 7_ J62 <br /> MAILING ADDRESS {''N''—tom' <br /> CITY 21 VW— STATE C l� ZIP <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 application and that the work to be performed wi be done ccordanc` wft# aLL SAN <br /> JOAQUiN COUNTY Ordinance Codes and Standards, State and Federal taus. <br /> APPLICANT'S SIGNATURE <br /> Date: <br /> Title: <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 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 /> Service Code <br /> Nature of Service Request: <br /> Assigned to <br /> Employee # Date _/—/— <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 /> REHS / / 5UPV �l / ACCT <br />