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• SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # 3��Oa RECORD ID # INVOICE # <br /> FACILITY NAME ��` /` BILLING PARTY Y / N <br /> i <br /> SITE ADDRESS <br /> CITY ��� CA ZIP <br /> OWNER/OPERATORCv p Cif BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING PARTY Y / N <br /> DBA PHONE #1 )� <br /> MAILING ADDRESS t V FAX # ) ~7 <br /> CITYC� STATE C ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PART <br /> i <br /> Page 1 of this form. <br /> I also certify that I have pre this application and that the k to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinan Codes an Sta ards, State eder S. <br /> c� <br /> APPLICANT'S S/IrGNAjURE �G1� <br /> Title• �f�Q�- ` I/ 11�, � Date: <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 relea fC11's <br /> all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC / ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is rovided to me or my represen�e <br /> Nature of Service Request: Fv d 4'f-Servi a Code <br /> Assigned toGC --_ Employee # Date <br /> Date Service Completed /�/�� Further Action Required: Y / N PROGRAM ELEMENT� f{Z� <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPV 7 /Z:!AL I UNIT CLK _/ / <br />