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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY Ib # ( RECORD ID # i INVOICE # =(9 S <br /> FACILITY NAME sf�=� BILLING PARTY Y N <br /> SITE ADDRESS l0y / Y Z C7 A <br /> CITY `��T\ 2 CA ZIP�� G� <br /> OWNER/OPERATOR ��/ /Lam— BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> FBOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR / �\ f� Q�- C' BILLING' PARTYY / N <br /> DBA Gs l� � �� PHONE #1 -; ` j CZ Z <br /> MAILING ADDRESS �/� �! �- ' FAX #`fp"` <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site t specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the party identified a W6 PARTY on <br /> Page 1 of this form. ,UN D <br /> I also certify that 1 have prepared this application and that the work to be performed will be done n eccor1Zg9!h all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. EN PUA/VJOgQUl <br /> APPLICANT'S SIGNATURE V/q�NM� T�"'EZ u <br /> / ION <br /> 11tle: l/7 �f / �'Z 1� Date: <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 /> Nature of Service Request: Service Code � -' <br /> (� r <br /> Assigned to Employee # (� �j Y' �' Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS /_ / Z SUPV _/ / ACCT J �I �/ UNIT CLK / / <br />