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'SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> FACILITY ID # RECORD D #` 1-1:24� INVOICE B r r;11 <br /> FACILITY NAME i /.e� > //!�� _ " iJ s <br /> '�d BILLING PARTY II . I Y <br /> SITE ADDRESS /Z2— .'4a'6��t 5P— <br /> CITY CA IIP <br /> OWNER/OPERATOR -// BILLING PARTY Ir / <br /> PHONE #I <br /> AAIIRES �` - `'`�` PWK 02 t > <br /> 7 CITY STATE i ZIP <br /> Arm a Lend Ilse Appiisetion >Y €else Loiaetiats teete <br /> CONTRACTOR end/or <br /> SERVICE REQUESTCNt BILLING PARTY / N <br /> i►NONE Bi { � ) `7. <br /> FLAILING ADDRESS u (% r.�' FAXEl& <br /> CITY STATE ZIP 1 �34 _ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site M&or project specific <br /> VHS/ERD hourly charges associated With this facility or activity wi€l be billed to the party identified as the BILLING PARTY on <br /> Page I of this form. <br /> I also certify that I have pr red this spptication and that the work to be performed mitt be dam in accordance with all $AN <br /> JOAQUIN COUNTY Ordinance Cates and Standards, State and Federal head. <br /> APPLICADITIS SIGNATURE <br /> Tilir: Date: <br /> Al <br /> AUTHORIZATION TO RELEASE INFORMATION! In addition to the above, when app€Iceble, E, the owner, operator or agent of sow. of <br /> the property Located at the above site address hereby authorize the release of arty and alt results, geotachnical data snV*r <br /> enviroriental/aite assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon se <br /> it Is aveiteble and at the same time it is provided to me or my representative. �qc� <br /> Nature of Service Request: J1I c. 7 /Cbn/ 't Service Code c �� <br /> Assigned to <br /> Date Service Completed /��i Further Action Required: Y / PRO" ELEMENT ���'✓ <br /> Fee Amount AmDunt Paid Date of Payment Psyment1y * Receipt 0 Check # Recvd By <br /> RE HS �/ /7/ ala "V �. Ait:ri % '7 J� uN11 CLK � j A <br />