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0 <br />SERVICE REQUEST /�SERVREO) Revised 8/23/93 <br />FACILITY ID # I I RECORD ID # � II INVOICE # <br />FACILITY NAME G( h 5 Fc,lBILLING PARTY Y / oI <br />SITE ADDRESS 30 L) 3 Soy Ch G - C <br />CITY "r2rAc`� CA ZIP <br />°I 5 3 -i C- <br />ERATOR -__ _ - [�li o� �.J}C 't �Lt^ ✓i5�� S-inC . BYLLYNG PARTY / N <br />DBA I�-�'l \� l� TZCPU PHONE #1 ()_ d <br />ADDRESS (oC7 IS�"¢'` �' PHONE #2 <br />CITY L' `-CA- STATE C ZIP <br />APN # � Land Use Application # <br />FSOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REOUESTOR cn <br />DBA <br />MAILING ADDRESS <br />CITY <br />STATE ZIP <br />SILTING PARTY Y / N <br />PHONE #1 ( ) <br />FAX # ( ) <br />c <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 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 />itle: 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 />at is available and at the same time it is provided to me or my representative. <br />Nature of Service Request: <br />Assigned to R.HSLA, M A TH Employee # <br />Date Service Completed / / Further Action Required: Y / N <br />Service Code <br />Date <br />PROGRAM ELEMENT 44 ' 4S - <br />Fee <br />S <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />REHS _/ / SUPV _/__J ACCT _J� UNIT CLIC _�_J' <br />