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SERVICE REQUEST (SERVREG) Revised 8/23/93 <br /> FACILITY ID # ,(RECOORRD I/D�11 ",���, (4— INVOICE # <br /> `. FACILITY NAME T// YrrON/�+�/�,j/�K�u Ffl'A��I�l�/e-timkfif & BILLING PARTY 7Y / ON <br /> SITE ADDRESS IBJ� G Ej{�l'F'( MILE 11� // '�,/��[ (A-( p ,04d 9,35 <br /> CITY ��h/ CA ZIP �TSWD <br /> OWNER/OPERATOR UA &Y r t)kN ON BILLING PARTY (� Y ��/q Nom, <br /> ORA p PHONE #1 (�) Ste- y9 Z7o <br /> ADDRESS 1-7 <br /> p�/p ' (DLG7NA1WU0b D4, PHONE #2 ( ) <br /> CITY int frEeA STATE t% ZIP Gs3�6 <br /> IAPN # Land Use Application # <br /> [BOB Df It I Location Code <br /> CONTRACTOR and/or <br /> aF#VIRF #RRUFSTOR �"� ...�._ _ _ BILLING PARTY Y / <br /> DBA PHONE #1 ��D571�1 <br /> MAILING ADDRESS 1217 S , -14t5t`q• P,¢ FAX # ( ) �Zi - 0J3 <br /> CITY AAPOUJTV STATE ZIP gOWI <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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 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 <br /> �Code and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> nt/ <br /> Title: �i(.( 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 and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH/D�IVU ION as soon as <br /> it is availmbte and at the same time it is provided to me or my representative. d <br /> Nature of Service Request: 0 L!� <br /> Service Code <br /> ' <br /> Assigned to �?\i C� I �w�tQ.V�Py.� Employee # �p pI Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 23 oat <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS / / SUP V / / ACCT / / UNIT CLK <br /> R <br />