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SERVICE REQUEST SEH 00 61) Revised 8/23/93 <br /> [FACILITY ID # Z 2 RECORD ID # O 2 INVOICE # <br /> FACILITY NAME C (�`" '` V BILLING PARTY Y / <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> BOSDist Location Code <br /> CONTRAC <br /> OR and/or <br /> SERVICE TREQUESTOR —SC44L�a—y <br /> [BILLING PARTY Y /p N <br /> DBA <br /> /e E PHONE #1 ( A'6 <br /> MAILING ADDRESS ✓d�>`'y '�/- ✓ ZzSrr 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 /> 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 /> Title:— Oz.t/x�a-` Date: <br /> 3" <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 /> 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 /> ,C_�� JJ 3• ` <br /> Nature of Service Request: P /C2 0-tP., 6%,� E Service Code 06 <br /> Assigned to A Employee # v�`u Date <br /> Date Service Completed 3 / l 5 / 0 1 Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 7� °" /7�( dG o/ ✓ l� <br /> RENS �/ /0 / I SUPV _/ / ACCT / / UNIT CLK _/ / <br />