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r • SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # C INVOICE # �00`0 <br /> tACiLIfTYYN(A�ME �TC iS �r+� �` BILLING PARTY / N <br /> SITE ADDRESS <br /> CITY CA ZIP J <br /> OWNER OPERATO BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # ELAM Use Application # <br /> :][1100S Dist Location Code <br /> r,ONTRACT /or <br /> SERVICE REQUESTORN�-c �����i�-�lt�AL �-�3�J-lV�� BILLING PARTY Y <br /> DBA PHONE #1 (ZO'f_) <br /> MAILING ADDRESS . �Uy FAX # ( <br /> Ci TY �-ocSTATE- ZIP '1'520� <br /> • BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of some, 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 PARTY on <br /> Page i of this form. <br /> i also certify that i have lication and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ord! anc des St rds, State and Federal laws. <br /> APPLICANT'S SIGNATURE cam- B <br /> Title: ��I-tt�� Date:��—, r7 l <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 ell 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: m Service code <br /> e--, <br /> Assigned to a Employee # © T I d Date 1 ?-/_ 6 / <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Q-3 , O C> <br /> . Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RFHS _/ / SUPS' _/ / ACCT / / UNiT C=LK / <br />