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SERVICEREQUESTREQUEST ...� (EH 00 61) Revised 8/23/93 <br /> FACILITY 1D # RECORD ID # Is <br /> {� Od L, <br /> �l l7J INVOICE # <br /> FACILITY NAME BILLING PARTY Y / Nfj <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / <br /> DBA PHONE #1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> p APN # FLand Use Application # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING PARTY Y / N <br /> DBA JPHONE #1 ( ) <br /> MAILING ADDRESS fz /.09 l,'ge <br /> -,7 0.Cl-- L-L),d��j FAX # <br /> CITY �TG�G` O✓J STATE CA/ ZIP 9 ZD!q <br /> BILLING ACKNOWLEDGEMENT: I, 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 LWI on <br /> Page 1 of this form. R FCFIVE D <br /> I also certify that I have prepared this application and that the work to be performed will be done in accord"61-with7allg% <br /> JOAQUIN COUNTY Ordinance Codes a Standards, State andel Federal laws. SAN JOAQUIN COUNTY <br /> APPLICANT'S SIGNATURE �J/�ZLc-ate L. �jfi-�� OUSLIC HEALTH SERVICES <br /> PP 1 / )� ENV'9L""2E TA6 HEA6TI f e1VISION <br /> Title: C�j n/ / / /�-/7 lj //,1 !� Date: J41.,/ -2 <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: Service Code <br /> Assigned to � � \ Employee # l,. — VS Date =/ - / J <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT Z <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 5� �(5G <br /> RENS _/ / SUPV / /_ ACCT _/_/ UNIT CLK _/ / <br />