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SERVICE REQUEST 46 (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) - <br /> ADDRESS PHONE #2 ( ) - <br /> CITY STATE ZIP <br /> APN # p Land Use Application # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING PARTY Y / N <br /> DBA PHONE #1 <br /> MAILING ADDRESS FAX # <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site arid/or project specific <br /> PNS/EHD hourly charges associated with this facility or activity will be bitted 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: 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 /> environvental/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 Requeestt::_ p Service Code <br /> Assigned to �y "',f_(U � Employee # 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 /> REHS _/ / SUPV _/ / ACCT _/_/ UNIT CLK _/ /_ <br />