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SERVICE REQUEST <br />(SERVREQ) Revised 5/13/93 <br />=FACILITY # ,'Y,)/; L� RECORD ID # =00, BILLING PARTY Y / \Y <br />FACILITY NAME <br />SITE ADDRESS <br />CITY <br />OWNER/OPERATOR <br />DRA <br />APN # <br />ADDRESS o �;0 , V cop�o �� ��J 1 PHONE #Z ( ) <br />CITY IQ r 1 C�1'1 STATETY, ZIP %D <br />�) <br />Census BOS Dist Location Code City Lode ------ <br />CONTRACTOR and/or f <br />SERVICE REQUESTOR <br />DBA <br />BILLING PARTY Y / <br />PHONE #1 ( ) <br />MAILING ADDRESS I,C I7 S( . , �`-�V �'� �" �� FAX # ( ) <br />CITY 1 ! I O QL- V STATE �l—/''� , ZIP / 3J <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 />1 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 />i AA <br />APPLICANT'S SIGNATURE <br />Tit <br />Z <br />Date: 060 �? / � / C C <br />l5 <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 />envirormental/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: <br />Assigned to ke" Employee # ` lr <br />Date Service Completed _/ / Further Action Required: Y / N <br />Service Code <br />Date <br />PROGRAM ELEMENT S J'd <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br />REHS/_/� _/__/_ ACCT _/ UNIT CLK _/_/_ <br />