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--- (SE v G) Revised 8/2J/qS <br /> SERVICE REGUEST - per!/_/ <br /> rACIL11Y ID N <br /> RECORD ID N INVOICE N <br /> nArIIITY NAME �J �/ 5y BILL IND PARTY Y _/ N <br /> SITE ADDRESS <br /> CITY S / CA ZIP / ✓ f�� <br /> fVNFR/OPFRATOR BILLING. PARTY � Y / N <br /> DBA /J Q' PHONE NI <br /> ��//�/�/ ( ) <br /> ADDRESS 7 T/ PHONE N2 ( ) <br /> CITY STATE ZIP <br /> -APR NLard Use Application N <br /> I A's <br /> — DOS Diet Location Code <br /> f.ONIRAC If1R and/or //'/ <br /> SERVICE REOUESTOR /���/ BILLING PARtY Y / N <br /> DBA oSw/) ��� PHONE 01 ( ) <br /> MAILING ADDRESS FA`%X 0 ( ) <br /> CITY STATE �-�C- ZIP O �� L �� �� 7 7 <br /> RILLING ACKNONLEDGEMENT: 1, the undersigned owner, operator or agent of came, acknowledge that all site end/or protect specific <br /> PHS/EHO hourly charges associated with this facility or activity will be billed to the party Identified at the BILLING PARTY on <br /> Pagi 1 of this form. <br /> N also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State a Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of acme, 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/mite 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 ServiceeRegjeest: /- Service Code 5 �' <br /> Assigned to ✓' �( ( Employee N ''lam Date <br /> Data Service Completed _ d- Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid bete f Payment Payment Type Receipt N Check N Recyd By <br /> 12 y ff <br /> UNIT-CLK <br /> RFHS L/ 7 / SUPV _/ / ACCT _/_/_ <br />