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-- SERVICE REQUEST — (EH 00 61) Revised 8/23/93 <br /> FACILITY ID N RECORD ID B i C// 5 7 INVOICE p <br /> FACILITY NAME <br /> A T <br /> SITE ADDRESS <br /> CITY SYv. ZIP <br /> OWNER/OPERATOR t'K.t ��j"'^"'� 1 BILLING PARTY Y / Q <br /> DBA OGV1I��C. T '7� A PHONE M1 ( <br /> ADDRESSJ0C7 �`Q na ^i1 t r �`�'�� PHONE U2 <br /> CITY ^ ( - STATE ZIP �S Z <br /> APN M p and Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or r <br /> SERVICE REQUESTOR <br /> DBA ,[A { PHONE p1 I ),�L2!' ` �6 <br /> MAILING ADDRESS IZJZSr&`� `SQ� '� C, FAX # I <br /> CITY —15 W N STATE _ - ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operato, or agent of same, acknowledge that alt 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 dofte feffa with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. NOV ��—��YY 7 <br /> N Y 6 199/ <br /> APPLICANT'S SIGNATURE 1 `-�"�`t � <br /> S' JOAQUIN COUNTY <br /> PUBUC HEALTH SERVICESI< �` —,�NVIRONnacu.., <br /> Title: Date:=�� DIVISION <br /> IVISipN <br /> AUTHORIZATION TO RELEASE INFORMATION: In additlon to the above, when applicable, 1, the owner, operator or agent of sane, 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 sane time it Is provided to me or my representative. <br /> Nature of Service Request: Service Code o 3 <br /> Assigned to ( J V i Employee B '1 2c Z Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT 3 <br /> E <br /> Amount Amount Paid Date of Payment Payment ype Receipt p Check # Recvd By <br /> C � <br /> REHS / L/yam SUPV _ _/_ ACCT <br />