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(ir ll ir3V1 <br /> SERVCE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECOR�[D # D? / INVOICE # J I� <br /> ILITY NAME �l[� BILLING PARTY Y' / N <br /> SITE ADDRESS � Hammer L8ne, <br /> CITY �/1/�G� �L/n CA ZIP <br /> OWNER/OPERATOR �(��ALf7 a r1�� Gvr BILLING PARTY Y / N <br /> DBA �i7/ PHONE #1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY 5 � ' iD STATE ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or , � ,� <br /> VICE REOUESTOR T GM �l ianin� CJF � 1rD+J� BILLING PARTY Y / N <br /> DBA {`iGC'� v�l` f� PHONE #1 ( ✓gyp ) <br /> W <br /> ` i O'.l Q �' <br /> MAILING ADDRESS IAV�� I �c� L �'`� FAX # <br /> CITY STATE 64 ZIP 0,45,zo, <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that a�j,j!7s1.-tFjVfi;)proJect specific <br /> PIIS/EHD hourly charges associated with this facility or activity will be bitted to the party identifie <br /> 2 11;jig�1LLING PARTY on <br /> D L <br /> Page 1 of this form. Cyl� <br /> 1 also certify that I have prepared this application and that the work to be performed will beP" ,�SHith all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal taws. ENVIRONMENTAL HEA IOi+ <br /> APPLICANT'S SIGNATURE /fes <br /> Title. / 10 Date: <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 /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the some time it is provided to me or my representative. <br /> Nature of Service Request: Service Code 0 <br /> Assigned to 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 /> Am <br /> RENS _/��7 SUPV __/ / ACCT lA / a / ' UNIT CLK <br />