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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # -n 3� ( RECORD ID # 0 INVOICE # <br /> FACILITY NAME BILLING PARTY I Y / N <br /> SITE ADDRESS <br /> c^-T <br /> CITY C C— /O CA ZIP 01 b <br /> OWNER/OPERATOR r UCL lJ d�.i dl L BILLING PARTY Y / N <br /> DBAT}{ V i-C) . PHONE #1 ( /c, ) a(/,)- <br /> ADDRESS ) C r PHONE #2 <br /> CITY )L��[ d � �_i STATE — ZIP <br /> APN # Lend Use Application # <br /> 1E =BOSDit I Location Code <br /> a <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR ►`lC, (�lor���✓d BILLING PARTY Y / N <br /> DBA $� M�rhO/�.c � �/ i_ .)��,UC LI&Al PHONE #1 <br /> MAILING ADDRESS -7rc SL_ FAX # FSC <br /> CITY � /�. �k( STATE ZIP / J/0� <br /> BILLING ACKNOWLEDGEMENT: 1, 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 PARTY on <br /> Page 1 of this form. <br /> PAYM E NI <br /> I also certify that I have prepared this application and that the work to be performed will be done in all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. v , <br /> JUN 16 1998 <br /> APPLICANT'S SIGNATURE <br /> SAN XAQUIN COUNTY <br /> Title:; LT ( Ctl Z �( Date: < 6 PUC UC HEA THSERVIC S <br /> �1-MMENTAL HEALTH DIVISIOl <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 renase 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 reprdentative. <br /> Nature of Service Request: Service Code <br /> Assigned to Employee # Date <br /> K <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 /> RENS / / SUPV _/ / ACCT _/ / UNIT CLK _/ / <br />