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.�^r• SERVICE REQUEST ;. ,fS iTe111257 W <br /> P.IL ITY TO N RECORD ID N 1N ICE R <br /> FACILITY NAME l C[�KJJ7v i�/V �./ -� F�11YG PAR_T+Y_- -- <br /> SITE ADDRESS �� �T �JYI D y-" otiv # <br /> CITY /IG9VCA.� CA ZIP <br /> n1W4FR/OPERAT0R l �/ (-j�r��f../ F / S T6 BILLING PARTY I Y �j/ L <br /> DBA PHONE N1 L <br /> ADDRESS �� 1/ (�1�GPN/ONE M2 ( ) <br /> CITY �(C�✓��L'Yll STATE ZIP % ?` J�S <br /> F—APR N p Land Use pp <br /> ROS Dist Location Code <br /> CONTRACTOR and/or <br /> SFRVICE RF.OUESTOR l f�Kl'��{f� f-Hj Uf BILLING PARTY Y / N <br /> DBA PHONE N1 ("j/G ) --IV7- <br /> MAILING ADDRESS FAX N l <br /> CITY STATE, ZIP 4 y S�—CJ <br /> RILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowtedge that ell site and/or project specific <br /> PNS/END hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> Pnqe 1 of this form. <br /> 1 nlso certify that I have prepared this application and that the work to be performed will be done In accordance with alt SAN <br /> JOAQUIN COUNTY Ordina s and Standards, Ste and F rel laws. <br /> APPLICANT'S SIGNATURE 1 <br /> f ��� <br /> Title: Date: <br /> i <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 es <br /> It Is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: f Service Code <br /> Assigned to B I I I div A-UE�U Employee N Date —/—/ <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT (% <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> REBS __/_/_ SUPV <br /> n <br />