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�. SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD 1D # c INVOICE # <br /> FACILITY NAME BILLING PARTY Y <br /> SITE ADDRESS (rJ T/ W• D� I/(�� 2-D �/v �NE � <br /> CITY CA ZIP <br /> OWNER/OPERATOR VQ NN ECDa<<fO� FEING PARTY Y <br /> BILL / NQ <br /> DBA '/ PHONE #1 <br /> 4&ADDRESS " �/ /2�J r��/" /zz)• PHONE #2' ( ) <br /> CITY I` STATE (//'1 ZIP 9-rJ t7 fP <br /> APN # Land Use Application # <br /> FIF ��r ���OC/ BOS Dist Location Code <br /> CONTRAC <br /> OR and/or <br /> SERVICE REQUESTOR l�1— !r/O/V ` gifly <br /> cv BILLING PARTY <br /> DBA PHONE #1 O �� - <br /> MAILING ADDRESS / S /`z €/"!'�L� FAX # ( ) <br /> CITY / // D�!/J l V STATE _ ZIP <br /> PAYAfiFwr- <br /> 4.—,.- <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 identifi".V lh S BJ[99KG PARTY on <br /> Page 1 of this form. <br /> JN(\ JVKQiJfi,. <br /> PUBLIC HE a �vts�l SAN <br /> I also certify that 1 have prepared this application nd that the work to be performed will-tie-;done,tilif�s� <br /> JOAQUIN COUNTY Ordinance Codes a andards, S e Federal laws. HEALTH DIV;,S,()�, <br /> APPLICANT'S SlI GGNNATURE <br /> Title: V ` P Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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: =Vret-� �O �vl- Service Code <br /> Assigned to '1 Employee # ? Date JI—/ <br /> Date Service Completed Ir / / ` ` Further Action Required: Y �/` N/ PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> VIZRENS / / SUPV _/ / ACCT (r —LL/—a/ qL� UNIT CLK _/ / <br />