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SERVICE REQUEST tEH 00 9'1) Revised 6123M <br /> ' (�� INVOICE # <br /> rFACILITY ID # RECORD ID # ( C) <br /> ' FACILITY NAME BILLING PARTY Y / <br /> SITE ADDRESS <br /> ' CITY CA ZIP y <br /> BILLING PART" � N <br /> OWNER/OPERATOR � 1 Ca® <br /> ' DIBA PHONE #`I <br /> ADDRESS A le Y� /��A-6?A-4-11,3 L' , � PHONE #2 8 ?CITY � rO Lr STATE�`��b d zip �j �� 7 <br /> APN # Land Use Application # <br /> 83OS Dist Location Code .,,J <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR �r �)' ®R '�-' � BILLING PARTY � J` <br /> p <br /> ' DRA �J �a PHONE #1rt <br /> SAID 0NG ADDRESS `'r /' 2 �'-� FAX <br /> ' CITY a — STATE z&P <br /> BILLING ACKNONLEDGEMENTe I, the undersigned owner, operator or agent of same, acknowledge that all site eWor project specific <br /> PHS/EHD hourly charges associated with this facility or activity witt be billed to the party identified as the BILLING PARTY on <br /> (Page I of this form. <br /> ' I also certify that I have prepared this appticatior, and that the work to be performed will be done in accordance with all SAN <br /> JDAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> ' APPLICANT°S SIGNATURE a , <br /> Title, Date- <br /> ' AUTHOR97ATION To RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> z <br /> the property located at the above site address hereby authorize the retease of any and alt results ata a or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E ► HEALTH DIVISION s <br /> ' it is available and at the same time it is provided 'to me or my representative, F� t <br /> 4 <br /> mo,ura of Service 4e <br /> Assigned to 'Employee #i ' Date <br /> Date Service Cffnpteted � ®/� Further Action Required; Y NT <br /> N PROGRAM ELEMEat <br /> 1 <br /> Fee Amount Amount Paid Date of.Payment Payment Type Receipt. # check. # Recvd By <br /> D R=9L'` SIIPV ACCT Li UNIT CLK: f' � <br /> 1 — <br />