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SERVICE REQUEIT1 1� ) <br /> - Revised 8/2S/93 <br /> • <br /> JEAC=ILI7YID # RECORD ID # NVOICE # <br /> FACILITY NAME C�1`t � x—� �� ` � � ' BILLING PARTY Y / N_ <br /> SITE ADDRESS <br /> CITY l�C d/ _ ZIP I�S � <br /> OWNER/OPERATOR L L IJ L- BILLING PARTY / N <br /> DBA PHONE #1 <br /> ADDRESS I�LY� �i K�ST f-Y{/' <br /> Le O� �l�X ?L,) ( i 6 $5 PHONE #2 ( 1v_, <br /> (Sguce, Cavyp e <br /> CITY C �}E�/Y(U STATE �L� ZIP <br /> qPN * Lend Use Application # <br /> BOS Dist Location Code <br /> .ONTRACTOR and/or <br /> iERViCE REQUESTOR BILLING PARTY <br /> DBA PHONE 01 ( ) <br /> MAILING ADDRESS FAX # ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> rHS/F..11D 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 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 <br /> Title,, <br /> 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 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 /> wNature of Service Requ s / ["/ G':L�/� I Service Code <br /> Assigned to (.)G G/ Employee # ��T Date <br /> Date Service Completed / / Further Action Required: Y / N [PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> q <br /> SUPV !f_f <br /> ACC i / f Li UN 1 T CLK <br />