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SERVICE REQUEST (SERVREO) Revised 5/13/93 <br /> y FACILITY [D # FRECORD ID # BILLING PARTY Y / N <br /> Rt 14 <br /> FACILITY NAME <br /> SITE ADDRESS /a�3 # DVJ <br /> C I TY ZIP 41 �` # a 1 Y <br /> n 7577 7 7177 lie <br /> OWNER/OPERATOR ��✓ L�-L� <br /> DBA PHONE #1 <br /> ADDRESS �-C�-J JJ 7 tiB Iti.�v /'U`�` - —�J -/ PHONE #2 C } <br /> CITY L�+� � STATE ZIP 7 <br /> APN # Census --------- SOS Dist Location Code City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR $T�� BILLING PARTY / H <br /> DBA �f PHONE #1 CIZ�) <br /> MAILING ADDRESS ��� �" `�-K✓ __'- FAX # ( } <br /> CITY STATE (ALJ ZIP <br /> BILLING ACKNOWLEDGEMENT: -1, the undersigned owner, operator or agent of same, acknowledge that alt 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 I have prepared this application and that the work to be performed will be done in accordance with at[ SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> I`t I <br /> APPLICANT'S SIGNATURE <br /> Title: Date: 4 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 /> envirormentat/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 tquest: Service Code <br /> As s, to /, C� <br /> sn�r.0 J Employee # Date <br /> Dat&Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> { <br /> .� Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> Z&3 - <br /> RENSL <br /> �/ / SUPV _/ / ACCT _/__f UNIT CLK <br />