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4 <br />7 <br />SERVICE REQUEST <br />(EH 00 61) Revised 8/23/93 <br />ID # <br />�S,Qj s_ Employee # J <br />/ Further Action Required: Y / N <br />RECORD ID # <br />o 3 Y <br />INVOICE # <br />FACILITY <br />Amount Paid <br />Date of Payment <br />Payment Ty <br />Receipt # <br />&4?S + Cr ro c -ey, <br />FACILITY NAME ,i <br />SITE ADDRESS / D I it��s T C �a r 1� WC4 <br />CITY <br />S�OLKTON CA ZIP <br />OWNER/OPERATOR J <br />DBA <br />ADDRESS <br />,.; _a' <br />BILLING PARTY 1 i / <br />BILLING PARTY Y / <br />PHONE 01 ( ) <br />PHONE #2 (—)-- <br />CITY <br />) <br />CITY STATE ZIP <br />ppN # lend Use Application # <br />BOS Dist Location Code <br />'IF <br />CONTRACTOR and/or / <br />BLG PARTY <br />SERVICE REQUESTOR5 ���4 Y / <br />DBA ID T L I 1 �!J ✓ PHONE #1 ( _) <-3 �v / <br />MAILING ADDRESS D FAX # <br />CITY r C STATE �_ ZIP 3 <br />BILLING ACKNOWLEDGEMENT: 1, 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 ident! thheBILLING PARTY on <br />Page 1 of this form. i1?fFCE1E � <br />e <br />)EFO <br />1 also certify that I have prepared this application and that the work to be performed will be0" in n1daa ce with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State a Fe rat laws. 1199 <br />SAN JO <br />ENVIRnBLIC yEALTlu O-' N7Y <br />APPLICANT'S SIGNATURE : <br />Title: <br />��'rtEALTy DIVISION <br />{{ <br />Date: <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 />,. , ° „ stile —4 of the cwna time it is provided to me or my representative. <br />Nature of Service Request: <br />Assigned to D & W <br />Date Service Cw pleted / <br />�S,Qj s_ Employee # J <br />/ Further Action Required: Y / N <br />Service Code <br />Date <br />PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Ty <br />Receipt # <br />Check # <br />Recvd By <br />77 <br />RENS C/� �/ 1 SUPV _/ / ACCT// J UNIT CLK <br />