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SERVICEREQUEST (SERVREQ) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # �! 1 a J INVOICE # Q 3l, GG <br /> FACILITY NAME BILLING PAR tY Y / N <br /> 3�trZF. . <br /> SITE ADDRESS <br /> CITY _A1)�� {II. CA ZIP <br /> OWNER/OPERATOR V fav d1 BILLING PARTY Y / N <br /> NOMMN L <br /> DBA Q+'�,5.�. 1 PHONE #1 ?_{V FStS <br /> ADDRESS _-- . % U L-t YJG( y't�I !„JPHONE #2 { ) - <br /> �1 <br /> CITY 1J� STATE ZIP <br /> APN # Land Use Application # <br /> IFBOS Dist Location Code <br /> CONTRACTOR and/or 1 <br /> I+FRVIFF_ REQUESTOR - ,u0be+e'r-_ S BILLING PARTY Y / M <br /> DBA 1 L ' PHONE #1 ( ZC1 g ) 7 <br /> MAILING ADDRESS FAX <br /> CITY cf> STATE: ZIP <br /> L-3- <br /> i. <br /> f <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator oriagent 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� <br /> I also certify that I have prepared this pplication and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and S rds, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: �' Lam” 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 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 /> it is available and at the same time it is provided to me or/my:representative. <br /> Nature of Service Request: AZ;4-��(-Qaslr. • {'-11"lal Service Code <br /> 'fw SO!/ 4! !•/! <br /> Assigned to GCrye-rro... Employee # — �2r 1 Date / ff / Q-7 <br /> Date Service Completed / O / q 7 further Action Required: Y / PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 390 -- ,23y. o� rr 97 GEr�CKS 3as'3 <br /> �� I <br /> RENS �(�p / / 9� SUPV C / ACCT UNIT CLK <br />