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a Dais <br /> SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> rACILiTY iD # RECORD ID # INVOICE ! <br /> FACILITY NAME BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CiTY CA ZIP <br /> OWNER/OPERATOR 1n,/ BILLING PARTY Y / N I <br /> OBA ��` PHONE 01 <br /> // ( ) <br /> ADDRESS '76 ^/��/n�G �/� PHONE 02 <br /> CiTY STp� �/�' STATE �� ZIP <br /> I—ArN Land Une Application K <br /> 4-9 ' Zvp —� ��� �Z d 2 /7 ROS Dist Location Code j <br /> rnNTP.ACTOR and/or <br /> SERVICE REQUESTOR r/EG`— �• ��(Oc�/Lrpyr ��SrC BILLING PARTY Y / N <br /> DBA PHONE 01 (ZDV ) Y7Z- IO `t/ !`r <br /> MAILING ADDRESSFAXZ(p Gd/U�/�/�G- /TLE fZIG <br /> U � FAX * (2 ) Y7Z- /6 y <br /> CiTY S� STATE C Zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site end/or project specific ! <br /> PHS/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 /> 1 also certifythat 1 have ave prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes a ndards, State and Federal laws. l <br /> ,) i <br /> APPLICANT'S SIGNATU_ v <br /> Title: Date, <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 /> envirornnental/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 Re nest: !!l, Service Code <br /> Assigned to (/ E to ee N V <br /> m'P Y Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check 0 Recvd By <br /> 01) <br /> SUPV _/_� ACCT _/_J UNiT CLK _/_/ <br />