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SERVREQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # b ` .VOICE # <br /> FACILITY NAME BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> APN # and Use Application # <br /> [fS Dist Location Code IF <br /> CONTRACTOR and/or "— <br /> SERVICE REQUESTOR �i 1 L4 W BILLING PARTY / N <br /> DBA r' (/'� `y/ 4� [ i/" ✓ GY V ', U ''i�- Y 1 1 r HONE #1 (�)��- ( 9 <br /> MAILING ADDRESS �V�C� `s L"Pn C�Jq fAX # <br /> r <br /> CITY ii l.. 1 STATE ZIP V C)WE) <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 have prepared this application and that the work to be performed will be done in acc dance with all SAN <br /> JQAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. s='YAIEN-4 <br /> APPLICANT'S SIGNATURE <br /> Title: Date: &ok FES <br /> 6d J(,AUUINL(,UNr} <br /> OUBt:C HEALTH SgAmp'-s <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, ope�adQSiT�h�drftEAdT>� 16i� : <br /> the property located at the above site address hereby authorize the release of any and ail 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 representative. <br /> Nature of Service <br /> Request: ✓ e(< I Pile U L I ft L) Service Code <br /> Assigned to � f Employee # (.Y2 <br /> 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 /> Ad V <br /> RENS / " / SUPV _/_� ACCT _J / UNIT CLK _/� <br />