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SERVICE REQUEST ^R (EH E1) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME -TaBILLING PARTY Y <br /> SITE ADDRESS / G �.• <br /> CITY L•^�� f- CA ZIP _ <br /> OWNER/OPERATOR �� �.�7 E .� b l"� _ BILLING PARTY Y / <br /> DBA PHONE #1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> FAPN # Lard Use Application # <br /> IF BOS Dist Location Code <br /> CONTRACTOR and/or ' I <br /> SERVICE REOUESTOR - ! F=ILLING / N <br /> t <br /> DBA /L�/F/ PHONE #1 ���/( <br /> MAILING ADDRESS \I/! -��� / / FAX # <br /> CITY �- �y-.f� a/ STATE 21P <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent 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 also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Fe aws. <br /> f / <br /> APPLICANT'S SIGNATURE <br /> Title: Date: / '" tz c <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 too me or my representative. <br /> Nature of Ser(((vice Reeq{u-es�t: � Service Code o_ <br /> Assign Xao �/.X/�-t� Employee # �L� 7y_ Date <br /> -Date Service Completed '� / / 1�i5 Further Action Required: Y / PROGRAM ELEMENT `'F 2-, 0 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �ou <br /> REHS _/ / SUPV _/ /_ ACCT / /i UNIT CLK _/ /_ <br />