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SERVICE REQUEST (SERVREG) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # <br /> INVOICE # <br /> FACILITY NAME SHEA �FOR/✓AL�da / F/1^oPE2.% BILLING PARTY y / <br /> SITE ADDRESS S /y/g�. A,eTHv2 <br /> CITY TRALY CA ZIP <br /> — BILLING PARTY � / (^J <br /> — ..._ PHONE #1 ( ) <br /> .. PHONE #2 ( ) <br /> TE ZIP <br /> —APCN # Lard Use Alpliceti on # <br /> Z ZO,s <br /> IN �f �/ -/y BOB Dist Location Code <br /> CONTRACTOR and/or ./ <br /> SERVICE REOUESTOR /VE/L P. � <br /> �J 4,-1y&zs,-1 BILLING PARTY <br /> DBA 11/6/1- U. ANO E2$u.ti f-/yq't�G ZNG PHONE #1 190 1/ ) 3G - ?70/ <br /> MAILING ADDRESS 22- �✓, f/Ol�$iOrl Lam/ FAX # (909 333 - 8303 <br /> CITY Z--Op/ STATE G/j ZIP �SZ yd <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that a site C oject specific <br /> PHS/Elio hourly charges associated with this facility or activity will be billed to the party iden Fi-�VISUING PARTY on <br /> ( <br /> Page 1 of this form. MAR 995 <br /> SAN JOAQUIN OUNTY <br /> 1 also certify that 1 have prepared this application and that the work to be performed will li{EREdgytKiall SAN <br /> JOAQUIN COUNTY Ordinance Codes a Standards, S e and Federal laws. ENVIRONMENTAL HEALTH DIVISION <br /> APPLICANT'S SIGNATURE <br /> Title: � S�i7 % Date: /A /) <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 meor <br /> Amy re <br /> pre <br /> se <br /> ntative. <br /> Nature of Service Request: 7- Service Code q <br /> Assigned t Employee # Date <br /> Date Service Completed / /J�j Further Action Requi a YY / N PROGRAM ELEMENTZ- <br /> Fee Amount Amount Paiiid(�\� Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS _/ /_ SUPV _/ / ACCT /�/ UNIT CLK _/ / <br />