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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # �j/ y INVOICE # <br /> FACILITY NAME J v' l..L BILLING PARTY Y / <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR / — BILLING PARTY r Y / N <br /> DBAJ/ PHONE #1 <br /> A4, <br /> ADDRESS / / iU Z PHONE #2 ( ) <br /> CITY t-el �I�1 STATE ZIP <br /> rI-APN # Land Use Application # <br /> BOS Dist Location Code <br /> a <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR IJ l �, (IVI muyQ:) � FIBILLING PARTY Y / CN' <br /> DBA �1 PHONE #1 ( u'� > 3 (o(o!3 <br /> MAILING ADDRESS ' a W' �T�`�W�.Y� LfL - � 5" �tf- FAX # ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordprSAN <br /> JOAQUIN COUNTY Ordinance Codes and Standaarrdss,,]State and Federal laws. R E C EIV E.17i <br /> APPLICANT'S SIGNATURE / I <br /> AN 16 1998-- <br /> Title: Date: ' SAN JOAQUIN COUNTY <br /> PUBLIC NHEALTH��qSS�LERVICES <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator agent Toil salne;H gVISIOM <br /> the property located at the above site address hereby authorize the retbase 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 iscprovided <br /> " to me/or my,re�prOfentative. <br /> Nature of Service Request: /►O ( oC cr i y-tti-���%l C J C— Service Code <br /> Assigned to _ � 11IQLKl/1�.y( Employee # V 3� Date <br /> Date Service Completed �/ / Fu—L-Lrther Action Required: Y / + PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> L11 SUPV _/ / ACCT —/-/ UNIT CLK / / <br />