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SERVICE REQUEST (EH 00 bt) Revised 8/23/43 <br /> FEI <br /> ITY ID it RECORD ID # / 7 INVOICE # /1 -f <br /> FACILITY NAMEQ�`!/A-C Jam- =_8ILLINGRTY <br /> SITE ADDRESS �� / ��r� � _A <br /> ff ' ��7 .- <br /> CITY - l�� ��v/ CA Z 1 P <br /> OWNER/OPERATOR BILLING PARTY <br /> C� �1'I s PHONE #1 ( II <br /> DBA - <br /> ADDRESS �Z -2e—"4--/z4 PHONE #2 <br /> CITYSTATE ZIP <br /> 9 <br /> APN IN Land Use Application # --' <br /> FBOS Dist Location Code <br /> 5 <br /> CONTRACTOR and/Or <br /> SERVICE REQUESTOR _�f-r �^GI��•�CBILLING PARTY Y / N <br /> DBA <br /> MAILING ADDRESS ✓ !r FAX # <br /> CITY STATE ZIP <br /> 9 2�v <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent Df same, acknowledge that all site and/or project specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the party idpg V d as the BILLING PARTY on <br /> Page 1 of this form. r W kAIT <br /> RECEIVLrt) <br /> I also certify that I have prepared this application and that the work to be performed will Op" accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal taws. SRAd L / 1997 <br /> NV <br /> PUB�JC kAQUiry CQU1Vr,, <br /> APPLICANT'S SIGNATURE _ ren"'� <br /> LI rHC "— <br /> E's <br /> Title: !�- / Date:,_ / �~ SIQIV <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. l <br /> Nature of Service Request: Service Code sQL �___ <br /> Assigned to ~^ irployee # 03 -70 _ Date --SL/ 16 /_2 7 <br /> Date Service Completed /7�_ / Further Action Required: Y / N PROGRAM ELEMENT D <br /> 01 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS C9 T/ I 0 SUPV / / ACCT _/ / UNIT CLK <br />