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' SERVICE REQUEST [SERVREQ) Revised 8/23/93 <br /> FATALITY ID IT RECORD ID N INVOICE N 111 <br /> rAr.ILITY NAME sILLINO PARTY Y / N <br /> SITE ADDRESS <br /> CITY CA ZIP — — <br /> rAMFR/OPERATOR 1AA AA Ik- � t BILLING PARTY Y / �\ <br /> DBA Vd PHONE N1 ( ) <br /> ADDRESS PHONE N2 ( ) <br /> CITY STATE ZIP <br /> APN N p Land Use Applicatl on N <br /> IBOS Dist location Code <br /> CONTRACTOR and/or <br /> SFRVIf.E REOUESTOR Iv f-t"tl m. (�-FY(M P�QZZ A� BILLING PARTY Y. / N <br /> DBA PHONE 01 ( ) <br /> MAILING. ADDRESS 1�1"a �' W - ('i �,�� f�� AX N ( ) <br /> CITY ,,Y o t?'�1 <br /> JSTATE 21P "!/� <br /> c0al_ <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site and/or project specific <br /> CNS/ENO 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 /> 1 also certify that I have prepared this application 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 laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the strove, 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 dots 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 In provided to me or my representative. <br /> Nature of Service Request! _ T p Service Code <br /> Assigned to rr �a I t1 Employee N f J Q 'I Date <br /> Date Service Completed5/ / Further Action Required! Y /( N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> RFHS S/27 / ( SUPV _/ / ACCT ,�/a� / UNIT CLK _/ /_ <br />