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SERVICE REQUEST CEH 00 613 Revised 8/23/93 <br /> FACILITY ID # RECORD ID M <br /> INVOICE # <br /> FACILITY NAME BILLING PARTY T / N <br /> SITE ADDRESS <br /> • C17Y CA ZIP <br /> OVNER/OPERATOR BILLING PARTY Y / N <br /> ORA PHONE 01 ( ) <br /> ADDRESS PHONE 02 ( ) <br /> CITY STATE ZIP <br /> p APN It pLand Use Application # <br /> II BOS Dist LocationCode <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING PARTY Y / N <br /> BRA PHONE #1 ( ) <br /> MAILING ADDRESS FAX # ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, 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 also certify that I have prepared this application and that the work to be performed will be done in accordance with sit SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> T(tte• 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 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: Service Code <br /> Assigned to Employee At 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 Ry <br /> SUPV _/_/ ACCT _/ / UNIT CLK _/ /_ <br />