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SERVICE REOutai (SERVREG) Revised 5/13/93 <br /> FACILITY ID # RECORD ID f! BILLING PARTY =/ M <br /> FACILITY NAME <br /> SITE ADDRESS <br /> CITY <br /> CA ZIPv <br /> OYNER/ ERATOR ! BILLING PARTY <br /> DBA PHONE #1 ( ) <br /> ADDRESS i�{TD � /(/ , �1/�!O /�/J PHONE #2 ( ) <br /> CITY =J�i� STATE J�r ZIP <br /> APN # Census -- SOS Dist Location Code City Code - <br /> CONTRACTOR and/or 7 i <br /> TCt REQUEST. BILLING PART? Y N <br /> D8A DtIONE #1 ( ) <br /> MAILING ADDRESS fAX # <br /> CITY , L%/GLf STATE �lI� `L 1Jg3 Q <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agenViTf1 � that all site and/or pr�gGLape is <br /> PHS/EHD hourly charges associated with this facility or activity will be b fled to the party identified BILLING PARTY on <br /> Page 1 of this form. a <br /> I also certify that I have prepared this a icati and that the work toformed will be done in accordance with all SAN > (� <br /> JOAQUIN COUNTY Ordinance Codes and Stands , St a and Federal I / l <br /> lC <br /> APPLICANT'S SIGNATURE <br /> Title: Do <br /> - U <br /> AUTHORIZATION TO REL -INFORMATION: In addition to the above, en applicable, I, the owner, operator or agent of same, of <br /> the property jpeLffed at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirg3pental/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 /> Nature of Service Request: J Se"ica ode: Z-- <br /> Assigned to Employee Date: <br /> Date Service Completed: Further Action Required: <br /> PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS _/ / SUPV <br /> _/_f ACCT _/_� UNIT CLK _/_� <br />