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SERVICE REQUEST (SERVREO) Revised 8/23/93 <br /> FACILITY 10 # RECORD IO # INVOICNfr <br /> FACILITY NAME L/y�C.'/C �R L� Cy.Ji /)7GYa<C W/ Y�Z�'72/iG ���d BILLING PARTY Y / N <br /> SITE ADDRESS �G'�'�/3� ✓��d��Diti ✓C pyV /Qlj� /�; <br /> CITY ZIP <br /> OWNER/OPERATOR �'�� BILLING PARTY / N <br /> DBA �} PHONE 01 <br /> -7-7 <br /> ( ) <br /> ADDRESS 7C'�°� Ef/5 j��� �• ' 3 y t PHONE 02 ( ) <br /> fi n` <br /> CITY '���G�af'E STATE C'¢ ZIP ,� � N RU(Kpp, <br /> nrw MLand Use Application cat i on * R� <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING PARTY Y / N <br /> DBA PHONE #1 <br /> MAILING ADDRESS FAX # ( ) <br /> CITY STATE ZIP <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 WY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed wilt be done in accordance with alt SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal taws, <br /> APPLICANT'S SIGNATU°C . <br /> Title: Date: <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 att results, geotechnical data andlor <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 /> Nature of Service Request: �H:y� CjL�SU,e� Service Code <br /> Assigned to .d/// siC (a__ __— Employee # ©`'u 2 Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT =aC ;-Z' <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPV _/ / ACCT <br />