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FACILITY ID # <br />L <br />RECORD ID # <br />SERVICE REQUEST T1 00 ,Fy()_-(SERVREQ) Revised $/?3143 <br />�r <br />to <br />INVOi,CE # � [ <br />FACILITY NAME r / BILLING PARTY Y I L? <br />SITE ADDRESS <br />CITY <br />STOCK-7b'tJ CA zip 0_�5.26 7 <br />OWNER/OPERATOR J ii TI N Y % ri <br />DBA <br />>" ✓] C l t' 7 4-1V 1 ? PHONE #1 'I—) <br />ADDRESS <br />) (7 2 -5 <br />PHONE 42 <br />CITY <br />i' ,J <br />STATE �44 ZIP <br />APN # <br />Land Use Application # <br />SOS Dist Location Code L�j <br />CONTRACTOR and/or <br />SERVICE R£QUESTOR <br />�� r <br />- BYLLING PARTYY <br />r H <br />DBA <br />AA1k5 <br />�U <br />PHONE ill <br />3+ e <br />MAILING ADDRESS <br />I9 C <br />'q <br />FAX # ( <br />) <br />CITY <br />leP!5oi U <br />STATE �r ZIP <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 ] 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: <br />Date: <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br />the property located at the above site address hereby authorize the release of any ana 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 Request: / %1UK <br />Assigned to <br />Date Service Completed / / <br />Fee Amount Amount Paid <br />RENS / / SUPV <br />J1 F(/- <br />Employee # (/' Il- 3 I <br />Further Action Required: Y / N <br />Date of Payment Payment Type VReceipt # <br />�J I ACCT I J <br />Service Code <br />Date <br />PROGRAM ELEMENT '_-�7-3 <br />Check # ! Recvd By <br />UNIT CLK J �%� <br />