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t <br /> SERVICE REQUEST (SERVREQ) Revised 8/23/73 <br /> FACILITY ID I RECORD ID R INVOICE ® "` <br /> FACILITY MAH# Al T BILLING PARTY - Y ! M <br /> SITE ADDRESS _FAG <br /> /' <br /> CITY "Y CA ZIP INV# <br /> OWNrR/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE N2 ( ) <br /> CITY STATE ZIP <br /> r Arm I (Lard Use Appllcati on I <br /> — DOS Dist Location Code <br /> CONTRACTOR And/ar <br /> SERVICE REQUESTOR ,(,.,r BILLING PARTY / N <br /> DRA 5 //[i �`"e" PHONE 01 ( ) <br /> NAILING ADDRESS " I"//,/,/�`/ FAX M ( ) 7 <br /> CITY 'k4, STATE ZIP <br /> RII.LING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that sit site and/or project specific <br /> PIIS/EHD hourly charges associated with this facility or activity wilt be billed to the party Identified es the BILLING PARTY on <br /> Paq:i of this form. <br /> I nlso certify that I have prepared this application And that the work to be performed will be done In accordance with ell SAN <br /> JOAQUIN COUNTY ordinance Codes and Standards, Stole Federal lows. <br /> APPLICANT'S SIGNATURE <br /> Title! Date• <br /> AIIIHORIZATION To RELEASE INFORMATION: In sdditlan to the above, when appliceble, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby outhorite the release of any and all results, geotechnical date and/or <br /> environmental/alte assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is oveltable and at the gimme time It Is provided to me or my representative. <br /> Nature of Service Request- Service Code <br /> Assigned to C//�tJ0 Emptoyee I �pG / Dote <br /> f <br /> Dote Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date nt Payment Type Receipt I Check I Recvd By <br /> RFNS _/ /_ SUPV _/_/ AC 4T IL/ I / _ UNIT LK _/ /_ <br />