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SERVICE REQUEST (SERVREO) Revised 8/23/43 <br /> W ILITY ID N RECORD ID N� INVOIC <br /> IACILITY NAMEVILLI 0 RTY Y / N <br /> —� <br /> tim <br /> SITE ADDRESS IKIT/ {� <br /> YfiI�'1.� � . <br /> CITY CA ZIP <br /> OTJNE /OPERATOR BILLING PARTY Y / N <br /> DBA PHONE N1 ) z" <br /> ADDRESS PI(ONe *2 <br /> CITY STATE ZIP <br /> -APN p —Land Use Application N <br /> SOS Diet Location Code <br /> CONTRACTOR /or <br /> SERVICE RFOLIESTOR= Lt enc-�L` C Wit_L L?.r- u[:r BILLING PA R1Y Y / <br /> DBA PHONE 01 <br /> MAILING ADDRES T ����Q FAX N (1-_ 19 _ <br /> fl1Y_ STATE _ ZIP �SG U f <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 PARTY on <br /> Pnqe 1 of this form. <br /> I nlso certify that I ha re r tfile application en�f the work to be performed will be done 1n accordance with all SAN <br /> JOAQUIN COUNTY Ordinance s at lows. <br /> APPLICANT'S SIGNATURE : � \ � <br /> Title- Date- <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 end all results, geotechnical date arxl/or <br /> envlrormental/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 /> Nnture of Service Request: (� Service Code <br /> Aga(geed to h-c,`4 W\ <br /> Employee N '� � Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 2.3 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check,# Recvd By <br /> s � <br /> RENS __/ / SUPV / / ACCT _/ UNIT CLK �/ / <br />