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SERVICE REQUEST CEN 00 61) Revised 8/23/93 <br /> 4 <br /> FACILITY ID # RECORD iD # /D p� INVOICE # <br /> FACILITY NAME 71GC rS�cAf1 �lll►1KX �c l D(Sir rf F BILLING PARTY Y / N <br /> SITE ADDRESS �(/1Ct�bri, <br /> CITY b���L� /� CA ZIP <br /> OWNER/OPERATOR � 9n ll l _ (Lo DJ( NG PARTY Y <br /> OBA PHONE #1 (aQ —)-fiL- `f <br /> ADDRESS I I I N I P111Q ��l V e PHONE #z <br /> CITY �J� STATE ZIP <br /> APN # Land Use Application # <br /> IFBOS Dist Location Code <br /> c <br /> CONTRACTOR and/or r(' <br /> SERVICE REQUESTOR C'LAI rIn r BILLING PARTY Y / N <br /> DBA �Ir?Q 1/1\ �dRSC� IGl/y� PHONE #1 (��)� - 7��2— <br /> MAILING ADDRESS + � �XCLbfl�4 ��uI FAX # <br /> CITY STATE ZIP TVA <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, ope� orat agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or tivity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> 1 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 /> F0,Ai y13P <br /> APPLICANT'S SIGNATURE, :_ c3t� &L— r'f / , <br /> Title: o CC ( N- Date: <br /> AUC; 3 0 19gfi <br /> F��3,ly <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the ow46�/,RpFriii6dO-jqsppfir of.pame, of <br /> the property located at the above site address hereby authorize the release of any and all results, geoeCttnjcel'datq(and/or <br /> envirorvaental/site assessment infgFination to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVI1'011IAj. qpn 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 /> n31 <br /> Assigned to L t Employee # Date --F / 3; u/ I <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 /> Aa <br /> RENS / SUPV / / ACCT _/ /_ UNIT CLK / / <br />