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• • SERVICE REQUEST 46 (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # I, / /� a G INVOICE # 103 <br /> f <br /> FACILITY NAME BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> IAPN # p Land Use Application # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or , <br /> SERVICE REQUESTOR L.�_�(//Yl'�C J/BMJ )<,�C�T� , BILLING PARTY Y / N <br /> DBA J l}-L(/ �/1 t./5/ CG- L/ �1_l� PHONE #1 <br /> MAILING ADDRESS p•(J �d X 5 7n4 3q� FAX # ( ) <br /> CITY /.lC� 0/`1' 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 t/e 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 accordaiica 'uiihall SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> Gni / +ti�l� SEP 31996 <br /> APPLICANT'S SIGNATURE _ <br /> Sfitd `J Illf-JGT- -I, , <br /> PUBLIC HEALTH SE I <br /> Title: Date: //� /� (o r_NVIRnhiME'NTAL HFAL HVICES ' <br /> F. ru V151ph.' - <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 /> envirormental/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 /> �n �7 G <br /> Nature of Service Request: u �(Y ' ll--,Ie- Service Code / 0 <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 /> C, <br /> SUPV / /_ ACCT / /� UNIT CLK _/ /_ <br />