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SERVICE REQUEST (SERVREO) Revised 8/23/73 <br /> FACILITY ID N RECORD ID N INVOICE <br /> n <br /> rACILITY NAME 0ILLINg PARTY Y / N <br /> SIIE ADDRESS <br /> City CA ZIP <br /> rXn /nrFRAtOR BILLING PARTY <br /> i <br /> DBA 2( PHONE N1 ( ) <br /> ADDRESS ✓ !/(/ L. PNOONNEEE M2 ( ) <br /> �'G/ ZIP /�2 L o _ <br /> CITY / STATE _ <br /> (—MN N Le Use App l^catl a�NO — <br /> IIA S 9 <br /> TICS Dist Location Code <br /> CONTRACTOR and/or <br /> SFRVICE REOUESIOR � jS-!(/ /� � �� BILLING PARlY <br /> OBA 'j✓ ' PHONE 01 ( ) <br /> MAILING ADDRESS �/ �`� I FAXCN ( ) <br /> CITY r STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the udersigned owner, operator or agent of same, acknowledge that all site end/or project specific <br /> PNS/END hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> Pnge 1 of this form. <br /> I nlsn certify that I have prepared this oWt icatlon and that the work to be performed will be done In accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal low. <br /> APrLICANT'S SIGNATURE <br /> Tltlei Date: <br /> AIIRURIZATION TO RELEASE 1NruPmATiON: In addition to the above, when applicable, I, the owxr, operator or agent of 9", of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical date and/or <br /> envlrorreental/site assessment InformtIon to SAN JOAQUIN COUNTY PUBLIC HEALIH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It Is available and at the same time it Is provided to " or my representative. <br /> Nature of Service/Request: (D! / 7�7 ' Servicee Code <br /> "/ <br /> Assigned to /yQicl�i/�-�.i� Elryloyee N Uf0 T Lt Date d / —2 <br /> Dote Service Cospleted Further Action Required: Y / PROGRAM ELEMENt �� - Z <br /> Fee Amount Amount Paid Date of Payment Payment type Recelpt N Check N Reeve! By <br /> RENS _/ /_ SUPV _/ /_ ACCT _/_/_ UNIT CLK _/ /_ <br />