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iSERVICE REQUEST <br />MEN <br />rAC1LI1Y NAME <br />SITE ADDRESS <br />!TY <br />TQ() / _ CA ZIP / 'S <br />(SERVREQ) Revised 8/23/93 <br />fAf.tLI1Y iD # RECORD ID # <br />]]=NVOICE <br />[—BILL ING PARTY OY / If ' <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PNS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />Pnge 1 of this form. <br />nlso certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY ordinance Codes qnd Standards, state and Federal taws. <br />APPLICANT'S SIGNATURE <br />y�//� CIYY� Date. <br />Title: U i <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 date 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: T &&2 ifs I . <br />Assigned to 6-1'' <br />Date Service Completed <br />Employee # V 1 � <br />Further Action Required: Y / N <br />Service Code 3 <br />Date <br />PROGRAM ELEMENT r--� -3 , <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />GIfs1n0IT\\f-0d(�3 9`( <br />nWNFR/OPERATOR <br />A YY�� S T� 1�111�C l-� <br />Recvd By <br />I A b) -.aa <br />BILLING PARTY <br />1-18 - <br />DBA <br />ADDRESS <br />V Y , ` <br />I i 1;)� <br />y/ PHONE #1 ( OC ). 3/�a/�- S /$-aq / <br />lam 1 V,( ) f! 11I <br />PHONO <br />V �l <br />( �S I ' <br />TE <br />CITY <br />APN N <br />F <br />ti1� �. <br />STATE �.A <br />ZIP �J3� <br />Land Use Application <br />- <br />BOS Dist =L.cati.ne <br /># <br />_ <br />G S r 1 `-� <br />�j� BILLING PARTY <br />CONTRACTOR and/or <br />SFRVICE REOOESTOR <br />DAA <br />PHONE #1 (Q)Jv� <br />MAILING ADDRESS <br />l —f <br />FAX #)� �C - o <br />CITY <br />Ma( O O E S -nD <br />STATE l� <br />(� <br />ZIP % S 3 t-� , <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PNS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />Pnge 1 of this form. <br />nlso certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY ordinance Codes qnd Standards, state and Federal taws. <br />APPLICANT'S SIGNATURE <br />y�//� CIYY� Date. <br />Title: U i <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 date 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: T &&2 ifs I . <br />Assigned to 6-1'' <br />Date Service Completed <br />Employee # V 1 � <br />Further Action Required: Y / N <br />Service Code 3 <br />Date <br />PROGRAM ELEMENT r--� -3 , <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />I A b) -.aa <br />[ 3oa-.00 <br />1-18 - <br />,/ <br />I i 1;)� <br />— <br />RFHS / / SUPV _/___/ ACCT <br />