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SERVICE REQUEST (EH 00 61) Revised 8/2379 <br /> —T[FACILITY ID # RECORD ID # L� l 3 GI INVOICE # <br /> FACILITY NAME 4% BILLING PARTY Y / N <br /> SITE ADDRESS Com ' PAYM ENT <br /> CITY / CA Z I R3{M"r 1% n 4A(�_ <br /> v <br /> SANJOA IN COUNTY v+µ'l <br /> OWNER/OPERATOR PUB [: BILLING PARTY Y / N <br /> t:NVIRCNMENTAL HEALTH DIVISIO . <br /> DBA PHONE #1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> F APN # IF and Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR Y �(C �" ` 1�q0 ✓ I BILLING PARTY Y / NA-( <br /> DBA ✓�l V� V V 'e ( I//� a V I PHONE #1 (310 ) Y 7 2—S tis <br /> MAILING ADDRESS (( (1J (/�/ �J'�l rl V C. �! V P �O -f�l � AX # ( 310 ) K-T-3- ZS 7 J <br /> CITY 1-7 STATE Al ZIP �O9 - los �� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the party identified PAWENG PARTY on <br /> Page 1 of this form. <br /> I also certify that 1 hav7Ces <br /> ep ed thi application a that the work to be performed will be done in(� da a all SAN <br /> QU[N COUNTY Ordinance nd St dards, State a Fed rat laws. r <br />�;p01q <br /> LICANT'S SiGNATURE SAN JCJAMIN COUN1 <br /> �/�p �JENVIRONNIENir+l.HEALTH DIVISIONTitle: Ho V e Date: Z / <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. ^7 Q <br /> Nature of Service Request: Service Code <br /> Assigned to 9Employee # D�Y Date /0 1-4-17— <br /> Date <br /> 4-17— <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT U� <br /> F%e Amount Amount Paid Date of Payment Payment.Type Receipt # Check # Recvd By <br /> 4 <br /> REHS lU/ / SUPV _/ / ACCT ��/� UNIT CLK _/ / <br />