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SERVICE REQUEST CEN 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> i <br /> I <br /> FACILITY NAME � I I� LI <br /> LINO PARTY Y <br /> SITE ADDRESS <br /> CITY ( CA ZIP <br /> I i <br /> I <br /> OWNER/OPERATOR 6', ! BILLING PARTY Y ! N <br /> (' 2 <br /> DBA <br /> PHONE #1 <br /> ADDRESS 1� D PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> /1 <br /> =Bosoist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR UV� _.� BILLING PART(Y� Y / N <br /> DBA L I /J�C PHONE #1 ( lU) • <br /> MAILING ADDRESS f»( ✓���� ����', �� �_ FAX 11 <br /> CITY STATE ZIP J 742 <br /> I <br /> BILLING ACKNOWLEDGEMENT:i 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 /> I also certify that I halve prepared this application and that the o to be performed will be done in accordance with all SAN <br /> JOAouiN COUNTY Ordinance, Codes and St ards, Sta a end Federat L <br /> i r <br /> APPLICANYIS SIGNATURE : I <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 ani and all results, geotechnicat data and/or <br /> e vironmentat/site assessment information to SAN 30AOUIN COUNTY PUBLIC HEALTH SER�ICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is available and at tips same time it is provided to me or my representative. ! <br /> i <br /> Nature of Service Request: Service Code <br /> Assigned to Employee # Date _/ / <br /> I <br /> Date Service Compteted / / Further Action Required: Y ;/ N PROGRAM ELEMENT <br /> j <br /> Fee Amount Amount Paid Date of Payment Payment type R�ceipt # Check # Recvd By <br /> i <br /> I <br /> suPv ACCT / ! / UNIT CLK <br /> TOTAL P.02 <br />