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(SERVREQ) Revised 8/23/93 SERVICE REQUEST <br />Location Code SOS Dist <br />BILLING PARTY I / N <br />PHONE 01 ( )rhk- <br />MAILING ADDRESS ,15 21,4416-11' <br />STATE (1.- ZIP yR4-16 <br />Date: Title: <br />FACILITY ID N LI. 53-D RECORD ID N INVOICE 0 <br /> <br />FACILITY NAME <br /> <br />SITE ADDRESS 4(11 4 Ct-k rko <br /> <br />CITY <br />BILLING PARTY Y / Cr) <br />OWNER/OPERATOR <br /> <br />DBA PHONE 01 ( <br /> <br />ADDRESS PHONE 02 ( <br />/ N <br />CONTRACTOR and/or <br />SERVICE REQUESTOR SY(,l6f3() <br />DBA•Fc_I-1- -Fe (. g viOt hit-s <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 />rj) <br />, <br />, Fee Amount Amount Paid <br />T <br />Date of Payment Payment Type Receipt 0 Check 0 Recvd By <br />15 x 54--.d., <br />ra ,ou <br />3 1 . 5b = /I -V) I <br />ZIP <br />BILLING PARTY <br />FAX * ( <br />q 4 /1 <br />CITY r APN <br />STATE ZIP <br />i <br />== Land Use Application I <br />1_ <br />Nature of Service Request: I- 1 E <br />Assigned to /4/4-161 <br />Date Service Completed / / <br />Date Li / 5 / ;>.;17 / <br />Service Code 661 0-614)/6S <br />Employee 0 <br />Further Action Required: Y / N PROGRAM ELEMENT )/, <br />_1_1— REHS SUPV ACCT UNIT CLK