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R # - <br />SERVICE REQUEST j. <br />(EH 00 61) Revised 8/23/93 <br />FACILITY ID # <br />-I <br />RECORD ID # <br />Payment Type <br />INVOICE # <br />l� 1 <br />FACILITY NAME <br />SITE ADDRESS <br />CITY ���� ( CA ZIP <br />a <br />\C v-;> BILLING PARTY Y / N <br />PHONE #1- <br />,J1C <br />OWNER/OPERATOR <br />DBA <br />ADDRESS <br />CITY STATE ZIP <br />APN # r Land Use Application # <br />71 <br />CONTR and/or <br />SERVICE REQUESTO���—�r —C, <br />DBA <br />MAILING ADDRESS [ Cc, <br />PHONE #2 ( ) <br />PHONE #1 (�)1�a - <br />FAX # ( ( ) <br />CITY � C: -'VV6 STATE ZIP <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 identified as the BILLING PARTY on <br />Page 1 of this form. <br />I also certify that I hav pep ed tli a �' tion and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance es is State Federal laws. <br />APPLICANT'S SIGNATURE : ' �(e <br />Title• � '— Rs 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 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 />c. ;� —; inkip —A t the camp rima it is nrovided to me or my representative. <br />Nature of Service Request: <br />Assigned to yl V �J`Cp L Employee # y Date <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT �^ <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />62.9 • <br />2 1 2-3 L5s <br />37 <br />— -- <br />FSUPV <br />ACCT Z / ��% <br />I <br />UNIT CLK <br />