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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD 10 # 00 D INVOICE # V <br /> FACILITY NAME .k BILLING PAFP Y / N <br /> =J <br /> SITE ADDRESS EdfI r E 1) <br /> AP1 19°6 <br /> CITY ZIP SAN .1idV COUNTYk <br /> PUSUC HE COUNTY <br /> OWNER/OPERATOR BILLING PARTY YH DjvlgJpN <br /> DBA PHONE #1 ( ) <br /> ADDRESS f PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Land Use Application # - <br /> BOS Dist Location Code <br /> CONTRACTOR and/or e <br /> SERVICE REQUESTOR J BILLING PARTY Y / N <br /> DBA 5 PHONE #1 ( _)22-6 - - <br /> MAILING ADDRESS �� FAX # <br /> CITY STATE ZIP _I <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHO hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I ha a prepared i pplication and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance es and S ds, State and�iFederal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: v 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 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! v to <br /> ,ym�e or my representative. <br /> Nature of Service Request: -,(,Vi -tV Service Code /� <br /> 15.Qo <br /> Assigned to Employee # `J Date <br /> I �— <br /> Date Service Completed L4 / l / further Action Required: Y / N PROGRAM ELEMENT <br /> t <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPV ____/ / ACCTk� D'T/—a--/ !4 UNIT CLK _/ / <br />