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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # <br /> RECORD ID # `' ;� INVOICE # <br /> FACILITY NAME F'-V I �1�' S�S� �� O BILLING PARTY Y` / N <br /> SITE ADDRESS wATr-p-�o <br /> , CITY <br /> �To aY-To- CA Z I P R 52 5 <br /> Q�pV�.r-��, �, BILLING PARTY Y / N <br /> OWNER OPERATOR CH i-�P-o N 1 / '_ � ,�n <br /> DBA _ Fie,./F-0 ` r-aVLACxS Cb • PHONE 91 (��� ) ��4-�- 95_ <br /> ^,,.�� - PHONE #2 <br /> ADDRESS �CJ v <br /> CITY <br /> Cjdf.! N(t')IJ STATE CA ZIP <br /> APN # Land Use Application # <br /> BOS DA Location Code <br /> CONTRACTOR and/or EN r BILLING PARTY Y / N <br /> SERVICE REQUESTOR ` <br /> DBA ` n <br /> W E►�tlSf' C' NS CONS�'11p uCT1O1� <br /> C'x�� 3 ( ) " <br /> HAILING ADDRESS O FAX #_ <br /> ZIP <br /> CITY �OCKTQ� STATE CA— 9 S�'-1-1 <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. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards State and Federal laws. _ <br /> APPLICANT'S SIGNATURE m <br /> Title: ` <br /> ,p?'OJ' M GIz-- Date: 1c) �� 1 <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 rthereby authorize release fany ES all results, 9ndata and/or <br /> environmental/site assessment <br /> imaion to SANJOAQUINCOUNTY PUBLICHEALTHSERVICENVIRONMENTALHEALTHDIVISONasoon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Service Code `3 <br /> Nature of Service Request: <br /> Employee # Date <br /> Assigned to <br /> Date Service Completed / _/ Further Action Required: Y / N <br /> PROGRAM ELEMENT <br /> "7 <br /> � Receipt # Check # Recvd By <br /> Fee Amount Amount Paid Date of Payment Payment Type P <br /> SUPV _/ / ACCT <br />