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SERVICE REQUEST (EH 60 611 Revised 8/23/93 <br /> FACILITY ID # RECORD ID # / INVOICE # z.;. <br /> SICCING PARTY Y- / N <br /> FACILITY NAME <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> BILLING PARTY Y / N <br /> OWNER/OPERATOR <br /> DSA PHONE #1 ( ) <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> r APN # Land Use Application # <br /> BO5 Dist Location Code <br /> =====J <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR ��v���� BILLING PARTY Y N <br /> / <br /> DBA PHONE #1 ( ) lh- <br /> MAILING ADDRESS FAX <br /> CITY �Y///Dy� —� STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that ell site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity wilt be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed wilt be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance es and Standards, ate al Federal laws. PAYMENT <br /> RECEIVED <br /> APPLICANT'S SIGNATURE 1 f <br /> Title: C E&I <br /> 1 Date: JUL 81997 <br /> SAN JOAQLJ O <br /> AUTHORIZATION TO RELEASE INFORMATION: 1n addition to the above, when applicable, 1, the owner, opepg�FC Okyjjcl�gw. of <br /> the property located at the above site address hereby authorize the release of any and all resu NISTW99 (� WkThtQ r <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 R l est: Service Code _ <br /> Assigned to Employee # (� r/� Date / / <br /> Date Service Completed / / Further Action Recuired: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of P yment Payment Type Receipt # Check # Recvd By <br /> 4- <br /> SUPV / UNIT CLK / / <br />