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SERVICE REQUEST (Ell 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # r- INVOICE # q <br /> BILLING PARTY Y' / N <br /> FACILITY NAME <br /> SITE ADDRESS <br /> CITY �y"" CA Z I P <br /> OWNER/OPERATOR �1 C' BILLING PARTY Y / N <br /> :] <br /> PHONE #1 ( ) 04(-' <br /> DBA / _ <br /> ADDRESSNN ��-:�-Jb l (/(IVB PHONE #2 ( ) <br /> CITY STATE _ ZIP _� Z� �, <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> S REQUEST R bb RTY Y / <br /> / � c <br /> DBAiw n ♦ g ( aGC7 lY(ZI�AI�O , PHONE #1 ( ) <br /> -0 t <br /> AILING ADDRESS b V J �./ ,�Q N - �g FAX #- ( ) <br /> CITY STATE ZIP / <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project speci ' C <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. �y� <br /> 1 also certify that 1 have prepared this application and that the work to be performed will be done Y4%aWl with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. RECEIVED <br /> APPLICANT'S SIGNATURENN <br /> Title: Date: -AlTjoAOUIN COUNTY <br /> PUBLIC HEATH SERVICES <br /> N Q1 H t�yyVS IIOme, of <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the ownerVWWO&rN�-B pTi� 6f <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 we or my representative. <br /> -F Nature of Service Request: 1 _ A Service Code <br /> Assigned to !I ( _ L-j _ Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT i0 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> [REHS / / SUPV / / ACCT /' / / UNIT C:�� <br /> / <br />