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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> [FACILITY ID # y_ RECORD ID # .� /� y INVOICE # <br /> C- � 1 � PP l <br /> FACILITY NAME Sty& l� l/f11I1� �vlw' D�S�I lC� BILLING PARTY Y /l,N <br /> SITE ADDRESS I"1 �JI �II1Gt, blue �� <br /> CITY ��1� ^ CA ZIP � J <br /> OWNER/OPERATOR 9n On (1 l <(Lol DtJrtc-� BILLING PARTY Y / <br /> DBA PHONE #1 (20f )_fS�L- _ <br /> ADDRESS ( JV/ I(14 1 ��l U PHONE #2 ( ) <br /> CITY �S�fJ(/� STATE ZIP <br /> APN # and Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or f <br /> SERVICE REQUESTOR [� 1 C"1 f I Be r BILLING PARTY Y / N <br /> DBA i (n �dR�CN IGVy 1 PHONE #1 ( ) j - 7.):2 Z <br /> MAILING ADDRESS Iba�/ �XCCUI �I/� ��UY FAX # (M_)_ - _ <br /> CITYSTATE _ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, 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 as 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, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: )a tC (ft(-Ar Date: <br /> r'�' <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the ow41r'',/gF ton or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, Ji6iahnical dater"/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION*/,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 ( 3 <br /> Assigned to � Employee # 1 Date / 3 C;/ L <br /> Date Service Completed / / Further Action Required: Y / N [PROGRAM ELEMENT �, _�-�`�-7 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS ( / y SUPV _/ / ACCT F) Off/ D ✓/_ UNIT CLK _/ / <br />