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• SERVICE REQUEST - (SERVREQ) Revised B/Z3/93 <br /> r ACILt IY ID N RECORD ID N INVOICE N <br /> r <br /> IAC It ITr NAME / BILLING PARTY <br /> SIIE ADDRESS7- �_f <br /> CITY )�Lm JJ ///7 CA /ZIP ;-r,r— y/�O b / <br /> nnnlra/OPFRATOR /%//�G�!/ � t�lvv f BILLING PARTY <br /> DPA S ' // PHONE Nl ( ) <br /> ADDRESS PHONE 02 ( ) <br /> CITY STATE ZIP <br /> 1—APR N {=Land Use Application N <br /> Ic I DOS Diet Location Code <br /> CONTRACTOR and/or <br /> SERVICE REDUESIOR BILLING PARTY / Y ) / N <br /> DBA PHONE 01 ( ) �/ <br /> MAILING ADDRESS l ��l FAX N ( ) <br /> CITY l�0y`, STATE 21P T 241p / <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of some, acknowledge that ell site and/or project specific <br /> MIS/FHD hourly charges associated with thin facility or activity will be billed to the party Identified an the BILLING PARTY on <br /> Page 1 of this form. <br /> I nlsn certify that 1 have prepared this application end that the Work to be Pe formed will be done In accordance with all SAN <br /> JOAaUIN COUNTY Ordinance Codes and S ndards, e a ederel le <br /> APPLICANT'S SIGNATURE / <br /> Title: `�G ��/ <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of scone, of <br /> the property located at the above site address hereby authorize the release of any and all result#, 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 me or my representative. <br /> Nature of Service Request: �r S[/ �/ / jService Code 1 <br /> Assigned to (/, l�Ll�'/ �GL Employee N C11 1 Date <br /> Date Service Completed IO/ ,—�� / �' Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Recelpt N Check N Recvd By <br /> 3 D . <br /> y <br /> RFHS _1 / �� / I SUPV _/__/_ ACCT UNIT CLK _/ /_ <br />