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SERVICE REQUEST (SERVREQ) Revised 5/13/93 <br /> fACILItY ID # ECORD IO # BILLING PARTY Y / <br /> FACILITY NAME <br /> SITE ADDRESS <br /> CITY t — CA 2IP��� <br /> U <br /> OWNER/OPERATOR C t BILLING PARTY Y / <br /> DBA PHONE 01 (�) <br /> ADDRESS J05 /7/'' � PHONE #Z ( ) <br /> CITY s?�/ll. STATE ZIP �✓`� } % �/ <br /> APN # Census -------.. SOS Dist OV Location Code / City Code ------ <br /> CONTRACTOR and/or r <br /> SERVICE REQUESTOR BILLING PARTY Y N <br /> DBA PHONE #1 <br /> MAILING ADDRESS / �� � FAX 9 aZ92 o <br /> CITY STATE � ZIP J <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 wilt 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 perfo will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Sta rds, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: `Tn addition to the above, when a ica le, 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 ass �t information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERYICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available at the same time it is provided to me or my representative. <br /> Nature of Service Reques : Le lo,5alvService Code <br /> Assigned to : I Employee #: Date: <br /> Date Service Completed: further Action Required: <br /> PROGRAM ELEMENT r.4i000 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS _/ / SUPV _/_J ACCT _/_f UNIT CLK __/_/ <br />