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S <br /> SERVICE REQUEST 1EQ) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # <br /> FACILITY NAME B LING PARTY? / N <br /> SITE ADDRESS <br /> CITY I_ �0�7/v77 Y'y -- CA ZIP <br /> OUNFR/OPERATOR Ae-/�//QiZ� )� � /�jQ�� BILLING PARTY Y / N <br /> DBA "�- PHONE #1 <br /> C 7 <br /> ADDRESS ����e �j �'�U�- PHONE #2 ( ) <br /> CITY a0 ��G�� }`-�G�J STATE L ZIP <br /> APN # Land Use Application # <br /> Z c LOS <br /> Dist Location Code <br /> CONTRACTOR and/or L• <br /> SFgVICeF gFOUFgTAR __ -f 1i' 2%/ �-s��/ LERTYG PA / r <br /> DBA -- - f' ) PHONE #1 <br /> MAILING ADDRESS / C/G QYJ�����i (/C/�L/ FAX # <br /> CITY � Cl� STATE ZIP q.5 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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 Ordinancend Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE Codese�- ' <br /> Title: ��✓// ���/���✓ Date:- ems' <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 w- or my representative. <br /> Nature of Service Request: =S�/ �SGs�7��, / / /L� �/� ✓/L- -- Service Code <br /> Assigned to �LZ; /"' Employee # ,1 -3,7,/) Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT �G�i• �L� <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> fs�I 3► Z• I � �Lf7 <br /> RENS _/ / SUPV / / ACCT UNIT CLK _/ / <br />