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' SERVICE REQUEST (SERVREQ) Revised 8/2.3/93 <br /> FACILITY ID # RECORD ID # INVOICE # �w q O 1,� <br /> FACILITY NAME F g'AroK15 �l.fE �r BILLING PARTY Y / \NJ <br /> SITE ADDRESS 30-7a �Z- <br /> CITY Yv Kx.VI"��� CA ZIP 9& <br /> OWNER/OPERATOR FW,,akRPAYMENT <br /> � BILLING PARTY Y / a <br /> r ! r-Ly <br /> DBA N kJ ��V � � MAY 3 0 415 PHONE #1 <br /> AA 1Gf (J!N <br /> PULG --I�1.I.ADDRESS PHONE 02 ( ) <br /> ENVIRONMENTAL HCALTr! DIViSIGN <br /> CITY STATE ZIP <br /> nru +w l.arxi llAe Application # — I <br /> BOS Dist Location Code <br /> CONTRACTOR and/or .,- <br /> SERVICE REQUESTOR �hl�wS W1,41 ►y Fh��tl ��C - FB1LL <br /> PARTY ® / N <br /> w <br /> DBA PHONE 01 ( << ) - ZJ :�kQ <br /> MAILING ADDRESS 24P I C' FAX # ( )-��v- — _ <br /> CITY I L� `�CY� STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/END 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 /> df ,L <br /> I also certify that i have prepared this application and that the work to be performed will be done RIEr�ic-with all SAN <br /> JOAQUIN COUNTY Ordinance Codes tandards, S to a eral laws. MAY 3 ® 1995 <br /> APPLICANT'S SIGNATURE r''`'` <br /> PUBLIC HEALTH SERVICES <br /> Title: ��/t)��-/� Date: . ENVIRONMENTAL HEALTH DIVISION <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 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 anti at the same time it is provided to me or my representative. +/� <br /> Nature of Service Request: t,l Service Code I"I I!J <br /> Assigned to �0 k,Q2 WC I Employee # �J :2 -5 Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT -3 CJ <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS SUPV _/ / ACCT _/ / UNIT CLK _f ! <br />