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SERVICE REQUEST <br />M <br />FACILITY ID # RECORD ID # INVOICE # <br />FACILITY NAME t I <br />SITE ADDRESS /f '76 tJ h61"1'E ;4V'e-' <br />CITY 24G4 CA ZIP �J��s3 6 <br />OWNER/OPERATOR <br />DBA <br />4*4. K <br />(EH 00 61) Revised 8/23/93 <br />BILLING PARTYL — 1, <br />Y / N <br />BILLING PARTY Y / N <br />PHONE #1 (_S10 ) e—f dO <br />ADDRESS / ALJ( S-74/4' PHONE #2 ( ) <br />CITY �i2G'B�J STATE_ ZIP /Y -S J% <br />F <br />APN # =Land Use Application # <br />BOS Dist Location Code <br />CONTRACTOR and/or (' <br />SERVICE REQUESTOR QH J ��N e 'r 7 C - <br />DBA <br />L <br />LLING PARTY Y / N <br />PHONE #1 ( 1(S ) 7 d'% - efd () <br />MAILING ADDRESS ! �(+ti� ` FAX # (Sa ) ri�i /`�V <br />CITY �. 0 W / STATE C4 ZIP / -! Sr J 7 <br />F <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 1 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 Fe rat taws. <br />APPLICANT'S SIGNATURE : <br />itle: //i✓1e�hl'2 ct 'z'J'J' Date, <br />�T—� <br />AUTHORIZATION TO RELEASE INFORMATION' In addition to the nbove, when applicable, I, the owner, operator or agent of same, of <br />Pe property located at the above site address hereby authorize the retease of any and all results, geotechnical data and/or <br />'envirorxnental/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: <br />Assigned to <br />Employee # <br />Service Code <br />Date / / <br />Date Service Completed / —/ Further Action Required: Y / N I PROGRAM ELEMENT <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />RENS I _/ / I SUPV I --/--- / ----- I ACCT I __/ /__ I UNIT CLK I / / <br />