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SERVICE REQUEST (SERVREG) Revised 8/23/93 <br /> FACILITY ID R RECORD ID N !,_ / INVOICE R <br /> TACILITY NAME -4f, iA z�e? MILLING PARTY Y / N <br /> SITE ADDRESS <br /> —7T 2 ,c TC-0- Yer ! �^ <br /> CITY CA ZIP <br /> OwNFR/OPERATOR /���GQ-j"7 7` (.G gLI�Q/ BILLING PARTY Y lj N <br /> DBA �4-L-1 PHONE /1 <br /> ADDRESSM2 <br /> /» //9 <br /> CITY ��C^ STATE ZIP <br /> IAPN M --�Land Use Application K — <br /> BOS Diat Location Code <br /> CONTRACTOR and/or <br /> SERVICE REGIIESTOR BILLING PARTY Y /� N <br /> DBA /„1// (—f7!'I/h tiJO /J��1 / PHONE 01 KG�/ )7�- - 127 <br /> MAILING ADDRESS _//-J/ Z /'�f� / / Lj�� CFAX7 E0 <br /> CITY /�' l�7'Y'� f.7/' STATE ��1 ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that al�fYa Ject specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party Idenuf�eAa,'V�1 LING PARTY on <br /> Page 1 of this form. �{{ � <br /> �N,nOV3 1994 <br /> 1 also certify that 1 have prepared this application and that the work to be performed will b%9 JdR V�ep v"Mh ell SAN <br /> JOAGUIN COUNTY Ordinance Codes and Standards. State and Federal laws. PUBLIC HEALTH SERVICES <br /> G/ 7ENVIRONMENTAL HEATH DIVISION <br /> APPLICANT'S SIGNATURETitle: f--E <br /> I / �`1���1e2� Date: A ,y a�, /�/9 - <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 me or my representative. <br /> Nature of Service Request: SService Code <br /> Assigned to GnR>�1 Employee N Date /-3_/�` <br /> Date Service Completed Further Action Required: Y / (�DPROGRAM ELEMENT Z�_Z 7-- <br /> Fee <br /> Fee Amount Amount Paid Date of Payment Payment T Receipt If Check A Recvd By <br /> l s qb,ov <<- l- a <br /> RFNS SUPV UNIT CLK <br /> 2/-t <br />