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SERVICE REdIESTc/ I "-SR # -- <br />(SERVREO ✓ aad-l�IP3 -a <br />FACILITY ID # <br />Amount Paid <br />RECORD ID # <br />C. In eo -) <br />INVOICE # <br />Check # <br />Recvd By <br />FACILITY NAME <br />SITE ADDRESS ayo uJ e%1- ek^--A"C g+-� 'Li <br />� <br />CITY -Aocl Fti CA ZIP 1 s 26 <br />OWNER/OPERATOR <br />DBA <br />ADDRESS <br />BILLING PARTY I Y // N <br />BILLING PARTY Y / N r <br />PHONE #1 (121"1 ) `L - S 261 <br />PHONE #2 ( ) <br />CITY STATE ZIP <br />IAPN # Land Use Application <br />BOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REDUESTOR �D'"Y ^"� 3 NOJS ?+� � "'�-/" � BILLING PARTY /;'�'4 <br />DBA PHONE #1 ( ` I�/ ) & <br />MAILING ADDRESS '�- 13 `"1 2 h-P_e" 1) FAX # ( ) <br />CITY P1c&-5 D-�-' STATE 0 A' ZIP I `f> f-"' "i <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 wilt be billed to the party identified as the BILLING PARTY on <br />Page 1 of this form. <br />I 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 />APPLICANT'S SIGNATURE <br />Title: �,;�� caw 5 iv\c, Date: t-) I3 <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 />Nature of Service 7Request: r��la n�n/��Y1�Y/ Service Code <br />Assigned to W� `J SIT Lam. 1 ' Employee # Cis �.�z_ Date <br />Date Service Completed _/_� Further Action Required: Y / PROGRAM ELEMENT z �• �0 <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />SUPV _//_ ACCT _/_ UNIT CL ��_' <br />