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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # J� INVOICE # 7O <br /> FACILITY NAME BILLING PARTY G N <br /> c <br /> ITE ADDRESS <br /> CITY CA ZIP <br /> NER/OPERATOR <br /> <�' 7 � BILLING PARTY Y <br /> EJr���A�'�_ <br /> DBA PHONE #1 <br /> ADDRESS '451 , / / ♦ P-0 PHONE #2 ( ) <br /> CITY � �� STATE `'/dam ZIP 41C-� <br /> APN # '— �Land Use Application # <br /> BOS Dist 1� Location Code <br /> ONTRACTOR and/or Ip <br /> ERVICE REQUESTOR 5 !P BILLING PARTY Y N <br /> / <br /> DBA �.0 PHONE #1 ( ) <br /> ( ) <br /> MAILING ADDRESS FAX # <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PIIS/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 /> A Y <br /> I also certify that I have prepared this application and that the work to be performed will be done in a{fplf�" J <br /> all SAN <br /> JOAQUIN COUNTY Ordinance Codes end S nMdards, State and F rat taws. MAY <br /> ��p "'''' <br /> 1 7`1997 <br /> APPLICANT'S SIGNATURE : <br /> P""11CHEA TrHSERVITY <br /> Title: -� L��� Date: CE <br /> viciv AL HEALTH DItiE <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of snhb, f <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 /' G t"Ployee # 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 /> 41 <br /> RENS �_/-7—/7Z' SUPV / / ACCT <br />