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SERVICE REQUEST <br />(SERVREO) Revised 8/23/93 <br />- --- <br />(ACILITY ID N RECORD iD # INVOICE 0 <br />iACILITY NAME <br />SITE ADDRESS <br />CITY �"�C—p 1t�--�w� CA 21P ?s���' <br />BILLING PARTY Y / N <br />wirP./. RATO)1�/ljl--i, ��1�=1 BILLING PARTY I Y / N <br />DBA PHONE ki <br />ADDRESS PHONE N2 (_)_- <br />CITY <br />)- <br />CiTY STATE ZIP <br />F <br />APN p Lend Use Application <br />BOS Dist Location Code <br />rONTPACT ► nd/or <br />SFP.VIr,F REQUESTOR ..��3.�1C1F-�F�"f�LCQ-6 F-�sc.p BILLING PARTY Y / N <br />DRA cry— PHONE M1 <br />MAILING ADDRESS _0 o '�`��� FAX N <br />CITY5-t-C�C— STATES -1''t ZiP <br />RiI.LING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific <br />PIIS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />Pnqe 1 of this form. <br />I nlso certify that i have :par a plication and that the work to be performed will be done in accordance with all SAN <br />JOAQTIIN COUNTY Ordinancel.Cod* St erds, nd Federal laws. <br />APPLICANT'S SIGNATURE <br />�' IW ,SEK, <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 end all results, geotechnical data and/or <br />environmental/site assessment Information to SAN JOAQUiN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIONa soon as <br />It is available and at the same time it is provided to me or my representative. 16 h <br />�•_—�PNnture of Service Request! Service Code <br />te:-�� <br />Assigned toice•----��� - — ' r��` • �, —. <br />Date Service Completed / / Further Action Required: Y / N I PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt ar <br />Check N <br />Recvd By <br />a-3If <br />RFHS I --/ / I SUPV I _/__/ I ACCT I1 `'L I UNIT CLK I _/ / <br />