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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # r'Vlo�t'UC� RECORD ID # St1/.�� I j -c �I INVOICE # <br /> FACILITY NAMElhILCSaG t� "— ""nom v BILLING PARTY <br /> SITE ADDRESS � 1`—(•��-- <br /> �,S,a <br /> CITY ��AI ��'n5�7JJ CA ZIP <br /> NER ERATOR Vv+`(i`. T`. -�tI�D t `VtTI�/� Y� BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # FLand Use Application # <br /> BOS Dist Location Code <br /> 006RACT and/or /� <br /> SERV CE REOUESTORUrtoc �2 BILLING PARTY Y A N <br /> DBA PHONE #1 <br /> MAILING ADDRESS CJ � v _ " / FAX # ( ) <br /> CITYSTATE ZIP�'�� 1 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, 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 <br /> mKT IVICIV I <br /> I also certify that ave prepr9red this pplication and that the work to be performed will be done iq'JGQ *)h all SAN <br /> JOAQUIN COUNTY Ordinanc 11 nd Stands State and Federal l S. <br /> DEC 2 91 <br /> APPLICANT'S SIGNATURE : - <br /> rM JOACMAN COUh,% <br /> 9t PUBLIC HEALTH Akt.CE <br /> Title: Date: Z FNVIRONPtp dLHEA1T : <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 sit 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 /> Nature of Service Request: � 'Vw � _ Service Code � <br /> Assigned to Employee # Date <br /> Date Service Completed _/_/_ Further Action Required: Y / N PROGRAM ELEMENT ' <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd B� <br /> G .yv <br /> RENS L' Lz-/ / SUPV /_/_ ACCT <br />