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4 SERVICE REQUEST & (EH 00 61) Revised 8/23/93 <br />w <br />FACILITY ID # 1� RECORD ID #I Mg� Y 7 1 <br />INVOICE # <br />FACILITY NAME 1- o IL e UJ(--) C6 6' I ri / Ino BILLING PARTY <br />SITE ADDRESS 2 ?:) ( 1 J I+W�l o0 ✓< <x, 1 <br />CITY 'r, CA ZIP x�)4V <br />OWNER/OPERATOR <br />DBA <br />EB <br />ING PARTYY / N <br />PHONE #1 ( ) 3 34 - ,716 <br />ADDRESS �c��1/ V ► 4'L 4:v'u PHONE #2 ( ) <br />CITY STATE ZIP <br />APN # Land Use Application # IF <br />BOS Dist Location Code <br />CONTRACTOR and/or i <br />SERVICE REQUESTOR r I l Y l l�Y �Y >-il� CJ Imo) BILLING PARTY Y / N� <br />DBA PHONE #1 )_3 <br />MAILING ADDRESS <br />FAX # (tel to ) 3-'2- ©mac 1 <br />CITY bO- :S (.� STATE l 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. p1�2 4t <br />--,%► ai JN <br />APPLICANT'S SIGNATURE : <br />Title: ( l lr� ts�G� ' 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 />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: <br />Assigned to 1b I -JC �.1� �c g{) y�� Employee # <br />Date Service Completed / / Further Action Required: Y / N <br />�Zt7f n i t • .'l 4 • _. & n. 2 v / _. <br />Service Code <br />Date/I L /�" I <br />PROGRAM ELEMENT Z, --') c CTC / <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />3©Uy <br />REHS * / SUPV _/ / ACCT j /�/ UNIT CLK _/_, <br />t <br />