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y SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # J� CJ Si INVOICE # <br /> FACILITY NAME ' ;) \4c,7�• ly )� �' p� `'� BILLINGPARTY �./ <br /> Y / (�IJ� <br /> SITE ADDRESS Z� /Y� C~ / 1 N� I\ S h_ <br /> CITY ( 2v CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y <br /> DBA PHONE #1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> FAPN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or _ y— `� <br /> SERVICE REQUESTOR / v, V/ 1� fn `�"- )\ c' BILLING PARTY ���yy CQ('� N <br /> DBA 1 ��} ICI 1f PHONE #1 (�U�) �.J 'I D <br /> MAILING ADDRESS ,� A K� ��// O Y'� I" J / FAX # <br /> CITYI'P�� P) /V STATE ZIPS <br /> BILLING ACKNOWLEDGEMENT: 1, 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 ifypgrgr� rice with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Stred's, State end federal l REHH SFr IEM//'V''FYYD <br /> APPLICANT'S SIGNATURE — C <br /> 8 <br /> Date: d <br /> Title: <br /> CC ) : f J naeL _, b 9C0 <br /> —7—EN RON�NENT�ITN SERVIC <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operotorl l��A6ij'9R�y OName, 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 (m7e or my representative. !, l I <br /> Nature of Service Request: � '� S CX- -L�(�7 O4 Service Code L/ 3 - <br /> Assigned to ^-�:�. v _ 4scy Employee # -1 1. 03 Date <br /> 7 <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ��3� , ��3ol�k ✓ Z- <br /> ! f� <br /> RENS SUPV /_/ ACCT I UNIT CLK _/ / <br />