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1W <br />SERVICE REQUEST (SERVREQ) Revised 5/13/93 <br />ID # <br />Date of Payment <br />RECORD ID # <br />6�3 <br />BILLING PARTY <br />Y / DN <br />— JFACILITY <br />FACILITY NAME <br />SITE ADDRESS <br />r <br />CITY J�u"fst1 CA ZIP ClS�o�'l <br />OWNER/OPERATOR S b �� , �%�Cf BILLING PARTY Y / � <br />DBA PHONE #1 (_) 6- SN0C, <br />ADDRESS �2i. �o.�� PHONE #2 <br />r <br />CITY A �Q�`l`c� (ice STATE �ja ZIP RUG , <br />Census --------- SOS Dist Location Code City Code ------ <br />r <br />CONTRACTOR and/or <br />SERVICE REQUESTOR ��--� \ CC, L!LLLING PARTY / N <br />DBA \' QJ�� �e l'+��� �` PHONE #1 (S_Q_) <br />MAILING ADDRESS 1� �OTS�� \f r FAX # (Sl0 ) &56-- +StA <br />CITY C�a,�\ N YU STATE ZIP C§sy aaz <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. <br />I also certify that I hav pre ed this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance odes ar <br />/ Sfanda , St to and Federal lads. <br />i <br />APPLICANT'S SIGNATURE : <br />1�!VLTLW <br />Date: —46 -?S— <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. <br />Nature of Service Request:!rvice Code <br />V <br />Assigned to �b V- ���+�-�— Employee # Date 'S_/10 <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z <br />Fee Amount Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />REHS _/ / SUPV� _/ / ACCT _/ UNIT CLK <br />a v— <br />