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5ERVICE REQUEST (EH 00'61) Revised 8/23/93 <br /> - <br /> FACILITY IO # D.Uf03fG'c � RECORD ID # INVOICE # <br /> �f�-'�-+-- fr� � �v� BILIINGPARTY Y.. / N <br /> FACILITY NAME ✓ •1P <br /> SITE ADDRESS `-l�'L !` ' IiA{�YYtt F � <br /> CITY CA ZIP <br /> OWNER/OPERATOR Tf�,GL" 1Y, '""ff"~�r N. BILLING PARTY Y. / N <br /> DBA I T"-� i %��. �,�i- � �. PHONE #1 Q�) r+. <br /> ADDRESS <br /> CITY . �Ar1F'1j_"4 STATE ZIP <br /> APN # and Use.Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR _ i�1�� '✓ c .�—' BILLING.PARTY / N <br /> _ DBA � F ,~aT' —`Tt='- _PHONE #1 <br /> MAILING ADDRESS 'C � � ....: a.!� _ _ FAX # ( _•..L, j f_ <br /> CITY 'j STATE ZIP <br /> 9 <br /> • <br /> _ <br /> F <br /> �r <br /> BILLING ACKNOWLEDGEMENT I,.the undersigned owner; operator or agent of:•same;:.acknowtedge that-'a I L..si teand/or project.specific. <br /> PHS/EHD hourly charges:associated with this facility or activity wilt.-be. bitted'to the party identified as the BILLING PARTY on <br /> _ - t <br /> Page i of this:-form <br /> I1also certify that I ei.`this application end thaT the.work to performed wilt be done in accordance with all SAH <br /> .. ..;. <br /> JOAQUIN COUNTY Ordinance Codes'and rds, State and F ral,laws <br /> APPLICANTts SIGNATURE <br /> Title. <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the ,•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 end all,results, geotechnical data and/or <br /> environmental/site assessnt.information to_SAN.JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at. the some time it is provided to me or my representative. <br /> Nature.of Service Request: Service Code <br /> Assigned to EnQloyee # _Date <br /> Date Service Completed - ��f''Fttrther Act on Required t Y J N:- PROGRAM ELEMENT - <br /> t __,.._ <br /> Fee.Amount Asacaat Peid Date of PaymeniC P t Type '.Receeptµ# `LL R Check # Recvd 8y <br /> },. <br /> RENS _/_J SUPV: /.• / ACCT / "'` uNET CLK <br />