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SERVICE REQUEST <br /> (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # a y 7 INVOICE # Jv <br /> BILLING PARTY <br /> FACILITY NAME �' Q <br /> SITE ADDRESS <br /> CITY -�vCTOI`4 CA zip c� <br /> OWNER/OPERATOR /tel 4A BILLING PARTY <br /> DBA PHONE #1 ( ) <br /> ADDRESS 1 Q 3 Q oy • PHONE #2 ( ) <br /> CITY l I STATE ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> �ON�T'RACj��).nd/,r QUESTOR SA �G�`Cbc`� BILLING PARTY <br /> DBA ( PHONE #1 (001 <br /> MAILING ADDRESS �� � � FAX # ( J( _)L�' 3 ` <br /> • CITY G--�T-25 7-0/4 <br /> STATE 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 PARTY on <br /> Page 1 of this form. N <br /> 1 also certify that I have prep this on and that the work to be performed will be done c with all SAN <br /> X11/Mr) <br /> JOAQUIN COUNTY Ordinance eS&A S ar , State a Federal laws. JA <br /> N 2 <br /> APPLICANT'S SIGNATURE <br /> --- 91997 <br /> ONtjUi <br /> Title: � [l�c Date: fVIR��gE'�LTN SES CES <br /> AL�ERLT <br /> �q DIV <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent 9f1"*, 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: Service Code _ <br /> Assigned to ��Y l� R Employee # 'tom I (1 Date <br /> Date Service Completed / / Further Action Required: Y / N [PROGRAM ELEMENT C) <br /> f Fee Amount T Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS Com/ I / r SUPV <br /> s <br />