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SERVICE REQUEST )) (EH 00 bt) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # O / L.. INVOICE 0 <br /> FACILITY NAME / (/�� BILLING PARTY Y / N <br /> SITE ADDRESS 72 <br /> CITY / ���.h'7CA ZIP �� G <br /> OWNER/OPERATOR !_i ` "� BILLING PARTY <br /> DBA -� PHONE #1 ( ) <br /> ADDRESS /Z,`/-7 "y(EE-/—yV a0 PHONE #2 ( ) <br /> CITY �C l"7')/ STATE ZIP <br /> APN # p Land Use Application # <br /> IBOS Dist Location Code <br /> CONTRACTOR end/or <br /> SERVICE REQUESTOR f /� " / BILLING PARTY Y / N, <br /> PHONE #1 <br /> / <br /> DBA _/ Jam( �� ) L <br /> ,� ' (��Z <br /> MAILING ADDRESS "2� FAX <br /> CITY STATE�� ZIP <br /> i <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified)*the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that 1 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, <br /> State and Federal laws. <br /> APPLICANT'S SIGNATURE � p' / <br /> Title: �� <br /> / /"/ �2� Date• 12— "2— ' / 5� <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. <br /> Service Code <br /> Nature of Service Request: <br /> Assigned to f x" �� yr "T '^�"�`"' Employee # t0 Date <br /> Dale Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> E k: <br /> SUPV _/_/_ ACCT _/,_/_ UNIT CLK _/ /_ <br />