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SERVICE REQUEST (EN 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # � !� <br /> FACILITY NAME / 1 /CIC) f(21 0 C �� BILLING PARTY <br /> SITE ADDRESS 3 — 3a C 420 t . 16 o <br /> CITY CA zip 95 <br /> OWNER/OPERATOR /he h 7 I �Pr f �4 e-7 _ BILLING PARTY Y / <br /> DBA PHONE #1 ( def ) -�--3V— 7 <br /> ADDRESS /T o & / PHONE #2 5- <br /> CITY _ l UY�dCSTATE��� 4 zip <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR [NG PARTY Y N <br /> /� <br /> PHONE #1 <br /> DBA <br /> MAILING ADDRESS r � (f 2!/O "'✓��wu FAX <br /> CITY /7U v` ti� 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 billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. PAYMENT <br /> I also certify that I have prepared this application and that the work to be performed will be done in accor C111V6TDSAN <br /> JOAQUIN COUNTY Ordinance CodWndndards, State a Federal laws. <br /> NOV1pA� <br /> 'Y YJJ <br /> APPLICANT'S SIGNATURE SAN JOAQUIN COUNTY <br /> / PUBLIC MENTAL <br /> SERVICES <br /> Title: �.t' �� �� / Date: <br /> GNVIRONM1t NTAL 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 and at the same time it is provided to me or my representative. <br /> 1 <br /> Nature of Service Request: Service Code('/ <br /> t� Employee # D�f� �f _ Date /__ /.Zz <br /> Assigned to � --77 ' <br /> Date Service Completed / / Further Action Required: N PROGRAM ELEMENT 3 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> eel <br /> �3 ' <br /> UNIT CLK _/_f <br />