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SERVICE REQUEST <br />FACILITY ID # , I I RECORD ID J <br />FACILITY NAME <br />SITE ADDRESS <br />CITY /� / ������ CA <br />OWNER/OPERATOR <br />DBA / <br />ZIP <br />(EH 00 61) Revised B/Z3/93 <br />INVQIC.E # <br />BILLING PARTY Y / <br />[BILLING PARTY Y / <br />PHONE #1 5 2C 3 <br />S I /U- J sw 711 ADDRESS PHONE #2 <br />fZIP <br />CITY `T'�'S�+/rU STATE <br />APN # — Land Use Application # <br />80S Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR�/C . 6;w /�f%/l��'I C.�// �' BILLING PARTY Y / N77] <br />r _ <br />DBA r PHONE #1 33 L I <br />MAILING ADDRESS � �� � J 75-p�CL9 n' FAX # 5 1 <br />CITY" C % STATE ,' f? ZIP 3d r� <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of &alae, 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 nark to �a porfQrmad Will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State an ,Federal law.*- WAR <br />/ i <br />APPLICANT'S SIGNATURE <br />Title: <br />C� <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the akave, when applicabta, I, the owner, operator or agent of same, of <br />the property located at the above site address hereby awthari;e the retea6v of any and all results, geotechnical data and/or <br />environmental/site assessment infOrwtian to SAN JOAQUIN GQUNTY KIBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is available and at the same tiwa it JS pravidad to me or my representative. <br />Nature of Service Request:\ ,1 Service Code l 9 <br />Assigned to �� w Employee # 9 9 V:) Dat• <br />Date Service Completed // Further Action Required: Y / N PRN" ELEMENT L' 3 6 - <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payw&nt Type <br />RacRipt 0 Ch.esk E <br />Raced By <br />I <br />— <br />- <br />REHS// SUPVJ /�/ AGCT _� /� UNIT GLJ� <br />0 <br />