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SERVICE REQUEST VRE0) Revt96"/23/93 <br /> FACIL�YlM RECORD ID * ITiN iC � <br /> I-Ar,ILITY NAMF 9 BILLING PARTY Y / N <br /> SITE ADDRESS # <br /> Tf ._ <br /> CITY CA ZIP <br /> OtJNF /OPERATOR V r BILLING PARTY Y / N ' <br /> DBA PHONE N1 <br /> ADDRESS PHONE 82 ( ) <br /> CITY STATE ZIP <br /> -APN N Land Use Application iY <br /> DOS Dist Location Code <br /> CONTP,ACTOR /or <br /> RFOUESTOR c31� lt7tVV -��C - ZytiE-�4C BILLING PARTY ( 1J / N <br /> DBA PHONE <br /> MAILING ADDRESS FAX <br /> CITY�TD/`t STATE ZIP <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 /> Page 1 of this form. <br /> 1 also certify that I have lication and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinanc C�de, S , Ste and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: <=_ \�G� Date:1/ 2 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicableI, the owner, operator or agent of acme, 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. <br /> Nature of Service Request: gggrvice Code <br /> LO <br /> Assigned to I KDL-0— �� uuz -' Employee k V 7 !I Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 2 3 . O <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt K Check 0 Recvd By <br /> RENS —/ / SUPV —/ / ACCT �/ UNIT CLK _/ / <br />