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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # t,- RECORD 1D # [� INVOICE # D 3 9-61 o�j <br /> FACILITY NAME (�L 1 � BILLING PARTY Y / <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWN OPERATOR E� � � ' BILLING PARTY Y C) <br /> DBA PHONE #1 <br /> ADDRESS f? PHONE #2 ( ) <br /> CITY cJ�� 1�`�' �� STATE CA ZIP 1AfrD0 3 -0g(!D4 <br /> APN # Land Use Application # <br /> 91-7 _ F BOS Dist Location Code <br /> CONTRAC <br /> OR <br /> SERVICEFB�� -` ff f�" �i`f�/� ✓ BILLING PARTY �/ N <br /> DBA tE; /A L g - PHONE #1 <br /> MAILING ADDRESS I 7�7 K. WPot,-IEU, BLVD. FAX # (30-7 )-76,5- 9909' <br /> CITY � -� STATE CA ZIP '{ 5 I <br /> BILLING ACKNOWLEDGEMENT: I, 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. P 4 <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. J L 1 0 1996 <br /> APPLICANT'S SIGNATURE 777-7 <br /> Title: Date: tNVIROnar�gENTAL HEALTH <br /> --�� 9i �9�I <br /> AUTHORIZATION TO LEASE 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 to me or my representative. <br /> h �,�. <br /> Nature of Service Request: Service Code <br /> .: �- <br /> Assigned to Employee # Date -/a—/ <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 3 1 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �n li��r ✓ 8s7o t <br /> REHS _/ / SUPV _/ / ACCT NIT CLK <br /> / _/ U _/ / <br />