SITE INFORMATION AND CORRESPONDENCE

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64x adq y6�-333 � 4(� (EN 00 61) Revised 8/23/43 i,e- 3�S"5 SERVICE REQUEST FACILITY [D # RECORD ID # INVOICE # FACILITY NAMEBILLING PARTY Y / N 4 ....... L SITE ADDRESS _ CITY y', CA Z I P OWNER/OPERATOR 11'G � �( _ BILLING PARTY Y / N D13A PHONE #1 ( ) �j J��/� _ ADDRESS a W1 PHONE #2 ( ) CITY I� a v ' ` STATE: ZIP !�� APN # Land Use Application # BOS Dist Location Cade FEi CONTRACTOR and/or SERVICE REOUESTOR BILLING PARTY Y N / D BA I� PHONE #1 ( ) MAILING ADDRESS FAX # ( ) CITY STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page I of this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and standards, State and Federal laws. APPLICANT'S SIGNATURE Title: Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or i environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as I it is available and at the same time it is provided to me or my representative. :t 1 Nature of Service Request: Service Code Assigned to Employee # Date Date Service,.Completed / 1 Further Actl ion Required: Y / N PROGRAM ELEMENT i Fee Amount ': Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By 5 SUPV _/�f ACCT _J / UNIT CLK �/ /