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SERVICE REoUFST VR4." <br /> 3 <br /> �� <br /> Mf.ILI1Y ID N <br /> RECORD ID N a , VOICE N <br /> FACILITY NAME �i BILL1140 PARTY t--• N <br /> SITE ADDRESS / v �` 4 j v <br /> c <br /> CITY CA ZIP <br /> (mjrR/OPERATOR BILLING PARTY Y / N <br /> DRA 4 PHONE N1 ( )� 2 <br /> ADDRESS �! �r PHONE N2 ( ) <br /> CITY I/ STATE ZIP <br /> f— <br /> Ar. N �{�Lend Use Application N — <br /> II 805 Diat location Code <br /> CONIRACIM and/or <br /> SERVICE RFOUESTOR BILLING PARTY Y / N <br /> DRA S PHONE N1 <br /> 1 3< S ( ) <br /> HAILING ADDRESS FAX N <br /> CITY STATE ZIP ! ' <br /> RILIING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all nit@ end/or project specific <br /> PNS/END hourly charges associated with this facility or activity will be billed to the party identified en the BILLING PARTY on <br /> Pngn'1 of this form. <br /> I nlso certify that I have prepared this application and that the work to be performed will be done in accordance with alt SAN <br /> JOAOUIN COUNTY Ordinance Codes and S ndards, State a eral laws. <br /> ArPLICANTS SIGNATURE <br /> Title: Date• / <br /> AIIIHORIZATION TO RELEASE INFORMATION: In addition to the above, when npplicnble, 1, the owner, operator or agent of came, 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 JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon ea <br /> it Is available and at the same time it Is provided to me or my representative. <br /> Nnture of Service Request- Service Code <br /> Assigned to � Employee N (YC��( Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amaint Amount Paid Date of Payment Payment Ty'-11 <br /> y Receipt N Check N Recvd By <br /> 6(, �� <br /> 7 / �� � <br /> RFHS' / / SUPV <br />