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SERVICE REQUEST ..� (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME T/y � G� `—� BILLING PARTY <br /> SITE ADDRESS / % i / /'�!� <br /> CITY-GT l��1�dG� CA ZIP <br /> OWNER/OPERATOR / i! �'�/ BILLING PARTY <br /> DBA PHONE #1 ( ) <br /> ADDRESS 1�`/ / / - � �� PHONE #2 ( ) <br /> CITY 4�1�/���� STATE _ ZIP <br /> FAPN # and Use Application # <br /> 1 BOS Dist Location Code <br /> CONTRACTOR and/or 4 �/+ <br /> SERVICE REQUESTOR �' !x%��� /47- / '�"� —� BILLING PARTY Y <br /> DBA �L�Y� /fes ��� PHONE #1 Z22)_ - <br /> MAILING ADDRESS / !� �1 /`�� FAX # <br /> CITY �cic�l� 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 accorda�Cpp�yy <br /> M$Ti N <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. Q C r;A <br /> APPLICANT'S SIGNATURE : �/ `� J U L 12 1995 <br /> � L- / / S N f JAQUIN COUNT`' <br /> Title: �j1�/ / /� /7�j/� / Date: i ,,,ell� /L// / <br /> 7 122 / /` EALTH SERVICES <br /> -.r\ P!MENTAL HEALTH DIVISION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 /> v � <br /> Nature of Service Request: }-L Service Code <br /> � rr <br /> Assigned to Employee # It Date -7 -/ f Z=-/ <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 2--L, <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPV _/ / ACCT �/ / UNIT CLK _/ / <br />