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SERVICE REOUEST (SERVRED) Revised LIM/" <br /> FACIU TY ID M RECORD ID M INVOICE #0D1 7-1 <br /> TAr..11ITY NAM! BILLING PARTY t / N <br /> 5 SITE ADDRESS ��gg <br /> CITY �i'��?F) CA ZIP ZZ __� II .• <br /> fAJNFR/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE NI ( ) <br /> ADDRESS PHONE M2 ( ) <br /> CITY STATE ZIP <br /> ('—APN # Lard Use Application N <br /> IBOS Dlat Location Code <br /> CONTRACTOR and/or c <br /> SERVICE RFQUES10R Z" KL cell c Z4 Cn�. — G BILLING PARTY Y N <br /> OBA PHONE #1 ( ) <br /> MAILING ADDRESS a � K \ U(� FAX ( ) <br /> CITY' `� STATE , ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/ENO hourly charges associated with this facility or activity will be billed to the party Identifled as the BILLING PARTY on <br /> Page I of this form. <br /> ------- <br /> I also certify that I hev p red this appllcatl on and that th work to be performed will be done In accordance with all SAN <br /> JOAQUIN COUNTY Ordinance tate and federal l . <br /> APPLICANT'S SIGNATURE <br /> ': < S <br /> title: c � Date: <br /> AUTHORIZATION 70 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 aft@ address hereby authorize the release of any and all results, g@otechnlcal date ardor <br /> rnvlrormental/Rite assessment Information to SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It Is available and at the same time It In provided to me or my representative. <br /> Nature of Service Regaeat: r Service Code G 5y <br /> T— <br /> Assigned to V I /vc�(J-Q-Y�� Employee # �/ .tom Date 9.(4" <br /> Date Service Completed / / Further Actlon Required: Y / N PROGRAM ELEMENT <br /> ree Amrro--nt Armunt Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> f <br /> RF HS _/ /_ SUPV ACCT _/_/ UNIT CLK <br /> -2- 3 <br />