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SERVICE REQUEST (EH 00 61) Revised 8/23/43 <br /> FACILITY ID # RECORD ID # L T INVOICE # <br /> FACILITY NAME 'l' n c� GAS BILLING PARTY Y <br /> SITE ADDRESS _ goo U,G <br /> CITY Loa, CA ZIP 9s-2 <br /> OWNER/OPERATOR )ac) BILLING PARTY Y ALI <br /> DBA PHONE #1 <br /> ADDRESS PHONE 92 ( ) <br /> CITY STATE ZIP <br /> APN # — Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or 0r <br /> SERVICE REQUESTOR LnoI E131LLING PARTY Y / N <br /> DBA PHONE #1 ( L7• ) L- LI <br /> MAILING ADDRESS /4 LCA L 1 .Q /2 /1 Lh FAX # ( ) - <br /> (� / a3 <br /> CITY L STATE ZIP '16 Z <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/END 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 /> APPLICANT'S SIGNATURE <br /> T`it1e: / Date: <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: Service Code <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 /> LEHS_ _/ / SUPV �/ / ACCT _/ / UNIT CLK _/ / <br />