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MSERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # O INVOICE # O 3� <br /> FACILITY NAME BILLING PARTY Y / N <br /> SITE ADDRESS �2 <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / N I <br /> DBA <br /> PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> P APN # p Land Use Application # / <br /> 111 I BOS Dist Location Code <br /> CONTRACTOR and/or - <br /> SERVICE REQUESTOR .�,/1 . BILLING PARTY Y / N <br /> DBA � 4t ) <br /> nn PHONE #1 <br /> MAILING ADDRESS -z� �/Lrt-gi/,*-(,i FAX # ( ) <br /> CITY -7 iLe.ary1,D STATE l' �� Zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all Sh6[And/of Sct 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 /> also certify that 1 have prepare this application and that the work to be performed will be Jonra 'i14EAccd0dSn6&Lwtthl;a4 l,;SAN <br /> JOAQUIN COUNTY Ordinance Codes a Stender s State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <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 at[ results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISJON 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: - ` <br /> -. Service Code Q <br /> Assigned to 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 /> RENS —I—IL— SUPV / / ACCT _/_ UNIT CLK <br /> � I <br />