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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> [FACILITY ID # RECORD ID # �`} t- INVOICE # <br /> FACILITY NAME ACL k F/ (�{J _ =BILLINGPARTY Y / <br /> SITE ADDRESS 77 00 lit <br /> CITY CA ZIP 9 57 02 <br /> OWNER/OPERATOR BILLING PARTY Y / <br /> DBA , p PHONE #1 (x <br /> ADDRESS O� t�V�� _ PHONE #2 <br /> CITY STATE ZIP <br /> APN # Land Use Application #IF <br /> BOS Dist Location Code <br /> CONTRACTOR and/or n ' <br /> SERVICE REQUESTOR �/ V BILLING PARTY <br /> DBA PHONE #1 <br /> MAILING ADDRESS S3S w FAX # <br /> CITY STATE C0— • ZIP 9-Se2 �s <br /> BILLING ACKNOWLEDGEMENT: 1, 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 I have prepared this application and that the work to be performed will be done in accordance with A'CiAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. . <br /> APPLICANT'S SIGNATURE J^Qj1�pp'' <br /> Title: p Date: �Ua °nlyl!4rCU�t''. <br /> T� �NVIRONN?ENTAL4A�F1i,GES(VISION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property iocated 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 /> Assigned to �` •moi ✓.Employee # l.° Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> EE <br /> ACCT _/ / UNIT CLK _/� <br />