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SERVICE REQUEST tEH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # I r() <br /> O INVOICE # —T <br /> FACILITY NAME (/ "� �!/ �% �'� �g BILLING PARTY 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 # Land Use Application # <br /> F Jr//{_ f ROS Dist Location Code <br /> _/O/ �� <br /> CONTRACTOR and/or )/ <br /> SERVICE REQUESTOR BILLING PARTY y / N <br /> � F <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS FAX # ( ) <br /> CITY STATE ZIP <br /> PAYMENT <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site ai /or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identi J "s2tKJ J"SIG PARTY on <br /> Page 1 of this form. VV <br /> SAN JOAQUIN COUNT <br /> I also certify that I have prepared this application and that the work to be performed will bei'NVfp^ all SAN <br /> JOAQUIN COUNTY Ordinance Codesand S ndards, State and Federal laws. ENTAL HEALTH DIVISICUI, <br /> APPLICANT'S SIGNATURE : /�}} �• <br /> Title: <br /> �• Date: <br /> AUTHORIZATION TO RELEASE 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 rdtlease 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 repr4entative. <br /> �� S S <br /> Nature of Service Request: <<� Service Code/ <br /> Assigned to z�� S Employee # �( / Date <br /> Date Service Completed _4_/ Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS //' / / SUPV _/ / ACCT _/ / UNIT CLK _/ _/ <br />