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SERVICE REQUEST (SERVREQ) Revised 8/73/93 <br /> FACILITY ID # RECORD ID it Oa INVOICE * V1 <br /> FACILITY NAME zm_ ivt BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY I• \DTrGC CA ZIP <br /> OWNE PERATOR �cf�lD1�� LT��C� BILLING PARTY Y <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE 02 ( ) <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> E7is BOS I Location Code <br /> CONTRACTOR /or <br /> S ICE REQUESTOROC��TDq c - lCr�TTD�y 4 %� G BILLING PARTY N''� <br /> DBA PHONE #1 CZ-0 q ) <br /> MAILING ADDRESS. WB FAX # )�-=�=— <br /> CITY —M6" STATE _ ZIP — � <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHD hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have pAthistion and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance e Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title.• 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 COLQ!VY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me ovvre representative. <br /> Nature of Service Request: 0 Service Code <br /> Assigned to loyee # Date <br /> Date Service Completed /_, Further Action Required: Y / N PROGRAM ELEMENT 0 O <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt Check # Recvd By <br /> REHS ACCT _J UNIT CLK �_f <br />