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SERVICE REQUEST — RVREQ) Revised 8/23/93 <br /> FACILITY Ib # RECORD iD # 5 0 Y INVOICE # <br /> d i` -- <br /> rACILITY NAME � �� ��i ()l�r✓ �JZL?1y BILLING PARTY Y / <br /> SITE ADDRESS -'Z�"t( LST YY IV11U -s7m�T <br /> CiTY P-1i:�io>j CA ZIP-9,!;. & <br /> (VNFR/nPFRATOR 546LL �l W���' � BILLING PARTY Y / <br /> DRA rr.' e � � ,,��,'�� yy PHONE #1 ( ) <br /> ADDRESS 1� �J W,U-CAJ' PHONE #2 (�[0 <br /> CiTY (^�� � STATE ZiP <br /> APN # IFanLd Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SFRVIrE RFQUESTOR � � C [ml��71�1/1 1 1 BILLING PARTY � / �N <br /> DBA PHONE #1 (S-1b ) 41c1-7- C,TCI <br /> MAILING ADDRESS �J V� �jCCTf NL `Jc() � + FAX 7- <br /> CITY �� [(J��)�'Ylt7►� _ STATE _ ZIP Cr �C, <br /> BILLING"ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific <br /> PIIS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Pnge 1 of this form. <br /> i n(so certify that I have prepar t a appllcat and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes r to a F laws. <br /> <1 ; p,`t yr <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> ,)EMIGE� 10N <br /> AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, 1, the ownrrlPI b 0��r a wslame, of <br /> the property located at the above site address hereby authorize the release of any arx! ell rachnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENWi HEALTH DIVISION as soon as <br /> It is available and at the same time it Is provided to me or my representative. -70Z�l <br /> Nnture of Service Request: r Service Code V , �_ _ <br /> 7� <br /> Assigned to 'D �,N� ZQa Employee Date / / <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 3. d <br /> Fee Amount Amount PaidDate of Payment Payment Type Receipt # Check # Recvd By <br /> f /T-V <br /> l <br /> RFHS __/__/ SUPV J__/ ACCT y/_ / JUNIT CLK _/ / <br />