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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> BILLING PARTY Y / N <br /> FACILITY NAME <br /> SITE ADDRESS ' J <br /> CITY / CA ZIP �3 <br /> OWNER/OPERATOR <br /> BILLING PARTY Y / N <br /> , <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Lend Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> BILLING PARTY Y / N <br /> SERVICE REQUESTOR <br /> PHONE #1 ( ) <br /> DBA <br /> MAILING ADDRESS FAX <br /> CITY STATE ZIP <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 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, St to and Federal laws. <br /> Lo�e:s U11+r +vrt-� of <br /> APPLICANT'S SIGNATURE <br /> Title: Prey 1 cienf Date: L I-ZaOI? <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 /> 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 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 /> SUPV _/ / ACCT <br />