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R# 3 - <br /> SERVICE REQUEST (SERVREQ) Revised 5/13/93 <br /> FACILITY ID # RECORD ID # BILLING PARTY Y / N <br /> FACILITY NAME <br /> SITE ADDRESS I✓ / <br /> CITY L) cJ J CA ZIP 5,31? — S7108 <br /> OWNER/OPERATOR 50 kki C G'�/ _. BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> APN # Census --------- BOS Dist Location Code City Code --- -- <br /> CONTRACTOR and/or C <br /> SERVICE REQUESTOR IJ �C'__ Y-U I L i yr;,P'7 / BILLING PARTY Y / N <br /> DBA PHONE #1 (2L4) <br /> MAILING ADDRESSi �/ J �� � FAX # <br /> CITY S tot- rl / U t'1 STATE Com_ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, 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 be 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 accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE / <br /> Title: 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 release of any and all results, geotechnical data and/or <br /> enviroraental/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: C: ti 1 Service Code <br /> Assigned to /,L) Employee # 0 /d Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 2 3, E 6 _ <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 43y-Go <br /> REHS S� ACCT UNIT CLK <br /> R <br />