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SERVICE REQUEST _. _ _,.,...-.4SE9VRI6 Revised 57'13'/43' <br /> FACILITY ID 0 RECORD ID # L NG Y / <br /> 971!Z <br /> FACILITY NAME "`-�' <br /> SITE ADDRESS -' <br /> CITY CA ZIP <br /> OWNER/OPERATOR =LINGARTY Y / H <br /> DBA PRONE #1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Census -------- I SOS Dist Location Code City Carie ----- <br /> CONTRACTOR and/or c � <br /> SERVICE REIXUESTOR BILLING PARTY Y / N <br /> DBA PHONE #1 <br /> -7 ( ) <br /> MAILING ADDRESS �� 7 ! FAX # <br /> t- "T ( ) <br /> CITY - STATE 7ZIP r 7 7 <br /> BILLING ACKNOWLEDGENENT: 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 wilt 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 ion and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance C 5t r , tat and Federat lags. <br /> APPLICANT'S S T <br /> ,— r <br /> Title Date: <br /> AUTHORIZATION TO REL ASE 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 rep[esentative. <br /> Nature of Service Request: �j Service Code <br /> Assigned to Employee # - Date / <br /> Dace Service Completed _(O /�/ Further Action Required: Y / (N } [_Z_umELEmENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS _/ / SUPV �/ / ACCT (0 1 UNIT CLX -!7=1 <br />