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SERVICE REQUEST (Eli OU 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # /11 ! INVOICE # DL{�f <br /> FACILITY NAME BILLING PARTY _ Y, / <br /> SITE ADDRESS <br /> CITY t 1 ii� CA zip aS j�jCP <br /> OWNER/OPERATOR I FallBILLING PARTY Y / N <br /> DBA PHONE #1 ( l ) L' Z <br /> ADDRESS 5(o PHONE #2 ( ) <br /> CITY C STATE 64 ZIP !5 3?:& <br /> APN # Land Use Application # <br /> r �� --'- � � !V-\�[�-7 SOS Dist Location Code <br /> C'iO-NTTR�{AACrTOOR/R and/or 1 1 1 ! <br /> SERVICE REQUESTOR 1 ,� BILLING PARTY Y / N <br /> ORA I ` PHONE 01 (401� )3L7-- -3761 <br /> MAILING ADDRESS z-� `��� QN ��-I(��j ---- FAX # t_� _ .) 333 - 8363 - <br /> CITY QSTATE Cf-'l ZIP 1�Z(40, <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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 /> PAYMENT <br /> I also certify that I have prepared this application and that tine work to be performed will be degggce with <br /> S all SAN i <br /> JOAQUIN COUNTY Ordinance Codes and Standards, to and Federal lows. F111I <br /> DEC <br /> APPLICANT'S SIGNATURE :J�� <br /> SAN JOAQUIN COUNTY <br /> Title- WDate: USLIC HEALTH SERVICES <br /> THDIVISION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of some, 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 �n at the same time it is provided to me or my representative. <br /> Nature of 5ervilCe Request: Service Code !7, <br /> Assigned to ERployee # 0 C) _ Date <br /> Date Service Completed / _/ further Action Required: Y / N PROGRAM ELEMENT H <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check p# Recvd By <br /> V1, <br />