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• SERVICE REQUEST <br />0 (SERVREO) Revised 8/02/93 <br />FACILITY ID # RECORD ID # INVOICE # <br />FACILITY NAME <br />SITE ADDRESS P / c/S <br />BILLING PARTY Y / <br />CITY CA ZIP <br />OWNER/OPERATOR 0, —rp, BILLING PARTY Y <br />DBA <br />ADDRESS <br />CITY <br />APN # <br />PHONE #1 ( ) <br />PHONE #2 ( ) - <br />STATE ZIP <br />Census --------- BOS Dist Location Code City Code -- --- - - <br />1 <br />tON�TRACTand/or ,/ wI <br />GUESTOR�� f �f✓/V V IN� BILLING PARTY Y / N <br />DBA S �/ Q /�!`/ PHONE #1 ( 57 <br />MAILING ADDRESS 'J / !///lA-7\-i !�j C/ 4411-7 FAX # ( ) <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent same, acknowledge that all site and/or project spec' <br />PHS/EHD hourly charges associated with this facility or activit ill be billed to the party identified as the BILLING4 TY 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 <br />JOAQUIN COUNTY Ordinance Codes and Standards -;"State and Federal laws. n 9-11 <br />APPLICANT'S SIGNATURE : <br />Title: Date.,., <br />AUTHORIZATION RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br />the pr y located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br />envir ntal/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIUIi as soo <br />i is available and at the same time it is provided to me or my representative. (/ <br />Nature of Service Request: r7 J /"l 1\J l 2 �' N ✓ Gn- L.-[.- "tel/G?l,`1P <br />Assigned to � 7 / 7/ y Employee # (/ / % (/ <br />Date Service Completed /_� Further Action Required: Y / N <br />Service Code <br />Date <br />PROGRAM ELEMENT -Z-a 6 b <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />REHS _/ / SUPV _/_J ACCT _/ / UNIT CLK _/ / <br />