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� 4 <br /> SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> FACILITY 1D # RECORD ID # INVOICE # <br /> FACILITY NAME Y Y(0 kJ� BILLING PARTY Y / (� <br /> 07C)5- C o z� c l I <br /> SITE ADDRESS .(, f �1R <br /> CITY _S 1 �` C l�40 CA ZIP 'D - <br /> -� <br /> IF <br /> OWNER/OPERATOR B LONG PARTY �- y <br /> / N <br /> DBA <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> SOS Dist Location Code <br /> CONTRACTOR and/or / <br /> 'RFRVIFF REQWFSTOR Y1Vl�D�/NfU*� 7r � f BILLING PARTY QR J M <br /> DBA 2 PHONE #1 (�) - 15 5-0 <br /> �3 <br /> MAILING ADDRESS r C /9^ P . FAX # (4a ) SY - '758 <br /> CITY 3051 STATE C4- ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that ell s W nuff specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identifi th ILLING PARTY on <br /> Page 1 of this form. <br /> SAN j0AQI!!N <br /> I also certify that I have prepared this application and that the work to be performed will beE�lPR - iwith/*.k; PN <br /> OAQUIN COUNTY Ordinance odes apd- ndards State nd Federal laws. h't T`{e r�F�l � 0"VISION <br /> i <br /> APPLICANT'S SIGNATURE l <br /> Title: C w,,(SIB e Date: —l <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 release of any and all results, geotechnical data and/or <br /> vironmental/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 <br /> is provided to me or my representative. <br /> Nature of Service Request: (� C� �J ". Service Code <br /> Assigned to _�Gt 02s., 0�� "I r Employee # Date <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 /> q <br /> RENS _/ � SUPV / / ACCT _/ / UNIT CLK _/ / <br />