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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # rt�3y5 "'INVOICE # 't' <br /> FACILITY NAME d�/ © /� �✓/ `� BILLING PARTY Y' / I <br /> SITE ADDRESS �IpO4 ' 6 � 1bT <br /> CITY CA ZIP ��L <br /> BILLING PARTY CY / N <br /> OWNER/OPERATOR L' �� � ` � ^ <br /> DBA i c,� /64 <br /> lnl�Y tl� PHONE #1 ( ) - <br /> ADDRESS / �./� 1U `"- — PHONE #2 ( )7-2:7 - � /� <br /> CITY �A( 6,j STATE _ ZIP <br /> APN # Land Use Application # <br /> BOS Dist <br /> EEa Location Code T7 <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING N <br /> PARTY Y / <br /> DBA PHONE #1 ( ) - <br /> MAILING ADDRESS <br /> FAX # <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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. ®® �p�ylp� <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in atcAYaMJEt*- all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, St anj Federal laws. RECEIVED <br /> A <br /> APPLICANT'S SIGNATURE 2 <br /> SAN JOAQUIN COUNTY <br /> Title: �r �? � Date: L EALTHSERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 /> envirorinental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same timeei/it is provided to me or my representative. <br /> Nature of Service Request: <br /> Assigned to Employee C��-ti �,. Service Code <br /> // 4 tL�� <br /> f„ to ee # Date <br /> Date Service Completed / _/ Further Action Required: Y / N PROGRAM ELEMENT <br /> a <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> Z ZZ L-ZZ <br /> RENS /� / 7SUPV _/ / ACCT _/ / UNIT CALK <br />