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• SERVICE REQUEST <br />0 (SERVREQ) Revised 8/02/93 <br />FACILITY ID # RECORD ID # J_ INVOICE # <br />FACILITY NAME M + i� i �� � v� BILLING PARTY I Y / N <br />SITE ADDRESS 2 <br />CITY /�%��%r vv/ CA ZIP J <br />OWNER/OPERATOR �.n�Q �� NJI/ / �"� BILLING PARTY Y N <br />DBA PHONE #1 ( ) <br />ADDRESS PHONE #2 ( ) <br />CITY <br />STATE ZIP <br />APN # Census--------- BOS Dist Location Code City Code ----- <br />ONT�/1CTOi� nd/or <br />SERVICE) UESTOR <br />DBA <br />MAILING ADDRESS <br />BILLING PARTY Ly <br />N <br />PHONE #1 ()_ N N y <br />FAX # (_)_- <br />CITY <br />)- <br />CITY n u STATE � ZIP <br />-�—ILIL <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. f ' <br />I also certify that I have prepared this application and that th, to be performed will be done in accordance,witha L <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. �✓� <br />X1, 9-1 <br />APPLICANT'S SIGNATURE <br />Title: Date: V <br />AUTHORIZATION TO RELEASE,IttFORMATION: 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 a7y.and all results, geotechnical data arid/or <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH ARVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is available and at the same time it is provided to me, orMjrgpr#�egtative. <br />Nature of Service Request: <br />/nl'C <br />Assigned to <br />Date Service Completed / / <br />Employee # <br />Further Action Required: Y / N <br />Service Code <br />Date —/—/ <br />PROGRAM ELEMENT Z <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />RENS _/ I SUPV _/ I ACCT _I_/ UNIT CLK _/� <br />