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SERVICE REQUEST �(EH 00 61) Revised 8/23/93 <br />FAC iLiTOY- ID RECORD ID # ) Q O INVOICE # <br />FACILITY NAMEc ` '�O ry rl-rnnen �C 1 own - �'4 [BILLING PARTYJ Y / <br />SITE ADDRESS ��-\ Q, ,� L� C �mw� r \ a v' -p <br />CITY r"C1 CA ZIP 0c7��1� <br />OWNER/OPERATOR �/`\ `C>Y n� - BILLING PARTY / -N1 <br />DBA PHONE #1)_- 3Zy i <br />ADDRESS 5D� `'� �"'°� ` `� t C`« (` PHONE #2 ( ) <br />CITY i�\rI`\ STATE_ ZIP 1�) <br />F/APN # Land Use Application # <br />fir 4I��(^} ` —�E BOS Dist Location Code <br />CONTRACTOR and/or p � 1 <br />SERVICE REQUESTOR ,/V11 n ot'` / BILLING PARTY Y / <br />DBA j L �b 7b 170 PHONE #1 ( ) <br />VU <br />MAILING ADDRESS S V Imo— �� ` / FAX # ( ) <br />—T <br />CITY <br />STATE ZIP <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 />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. <br />LICANT'S SIGNATURE : <br />Title: Date: l ytr 231 (Cecil' <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 to me or my representative. M/2n1V n <br />Nature of Service Request: <br />1 ►M I . I Service Code 0 <br />Assigned to T:�)o@5� Employee # L <br />Date Service Completed / / Further Action Required: Y / N <br />Date /_--L ? (Q <br />PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />Aftw <br />L�!O: <br />REHS I_/ / I SUPV I �_/ / I ACCT I r_�/ I UNIT CLK <br />Ion <br />