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SERVICE REQUEST (SERVREO) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # 30/ y INVOICE # <br /> W ILITY NAME �N© C BILLING PARTY Y / <br /> SITE ADDRESS 210 Lei r- `6,4r H A t C0 ,30 <br /> ` <br /> CITY rJ / TDl� CA ZIP <br /> OUNFR/OPERATOR /N 0 BILLING PARTY Y / 1 <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE _ ZIP <br /> F <br /> APN # —Lend Use Application # <br /> ROS Dist Location Code <br /> CONTRACTOR and/or P _ <br /> SFRVICE REOUESTOR �,F9LCI S /L�s� /h ! �/L!C� BILLING PARTY y / N <br /> DRA PHONE #1 <br /> MA i L I NG ADDRESS / t - O Y- ('C) FAX # <br /> CITY (?Y' /e C_./� STATE ZIP <br /> RILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledget /or project specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the party40the BILLING PARTY on <br /> Page 1 of this form. RECEIVED <br /> oy 18 1994 <br /> I also certify that I have prepared this application and that the work to be performed will in��mOr with all SAN <br /> JDAoIIiN COUNTY Ordinance Codes and Standards, State and Federal laws. SAN� <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICANTS SIGNATURE <br /> Title! �G' > � DED�?/ Date• <br /> --s <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 and all results, geotechnical date 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: JCService Code 1 <br /> Assigned to Employee # } _ Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT �J Q <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 23 a3 y S 3/0 <br /> RF HS _—/ / SUPV _/ / ACCT UNIT CLK <br /> - ---- <br />