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• SERVICE REQUEST3 Ct (SERVREQ) Revised 8/23/93 <br /> FACILITY ID >Y RECORD 10 INVOICE 0 79S <br /> rACI1-I1Y NAME J- ye-emcr= 1�}--�7;-71t�( / ��Gx-L BILLING PARTY Y / N <br /> e <br /> SITE ADDRESS tTT11tGL� l� T� <br /> n �� <br /> CITY y leF ' 6A ZIP q6 3• I tO <br /> r*P/OrERATOR k—/6BiLLING PARTY Y / N <br /> -y _r <br /> DBA /A �_ 14 1 Cr �. _ ( TONE kl (4 l 0 ) <br /> //�� •� Y.K1 GVL'�Ly- <br /> ADDRESS ©• LJO�C J20S, L��0 3� PHONE 02 <br /> CITY _ JC.i,I%��`f )�G STATE ZiP &' ��//' <br /> -APNN <br /> —IF <br /> Land Use Application # <br /> FBOSist Location Code <br /> CONTPAr,TOR nrxi/ <br /> SFRVIrE REOUESTOR BiLLING PARTY Y / N <br /> DBA PHONE M1 ( ) <br /> MAILING ADDRESS FAX ( ) <br /> CITY STATE ZiP <br /> Bit-LING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site end/or project specific <br /> PIIS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BiLLING PARTY on <br /> Pnqe 1 of this form. <br /> I ntso certify that I have prepared this application and that the work to be performed will be done in accordance with ll SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. OO <br /> APPLICANT'S SIGNATURE : <br /> L7 /Z <br /> Title: Date: <br /> AlIT14ORIZATION 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 date and/or <br /> envirormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is available and at the some time It is provider�d to me or my representative. <br /> Nnture of Service Request: att it, Service Code U <br /> Assigned to I �']1Ct�� Employee N (0-�, / �f� Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT _2 5 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt K Check Al Recvd By <br /> MVV <br /> RENS __/ / SUPV _/ / ACCT _/ / UNiT CLK _/ / <br />