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0 SERVICE REQUEST 0 (EH 00 61) Revised 8/23/93 <br /> ul3 INVOICE # �O <br /> FACILITY ID # ...��F�7777(��i•�/ RECORDID # 7 l/ l� <br /> FACILITY NAME <br /> SITE ADDRESS ✓Uj0�(1 b` ,'LiVI�'e- fl� ' q �y <br /> CITY CA ZIP <br /> OWNER/OPERATOR I2 q� Y / N <br /> DBA <br /> PHONE #1 <br /> ADDRESS �3'v � `I / PHONE 02 <br /> CITY �6LC' STATE �' ZIP <br /> APN # p Land Use Application # <br /> IBOS Dist Location code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR l-l/ BILLING�P7AR�TY Y �j'/ `-N, <br /> DBA PHONE #1 ( (N�'f�� <br /> 3 <br /> MAILING ADDRESS I�II�At `r " �`1 //(( FAX # ( 0�/ > V <br /> //�� <br /> CITY � o STATE t Ok 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 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 inec ,( tlan#e��with"^'all SAN <br /> JOAQUIN COUNTY Ordinance Code " nd Standards, State and Federal lava. MAR 18 19917 <br /> APPLICANT'S SIGNATURE SAfJ J)AQUIN GUUN TY <br /> q(yt f- ;r �ZtTf IQ� Date: ! PUBLIC HEALTH SERVICES <br /> Title: TAL HEALTH DIVISION <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 and all results, geotechnical date and/or <br /> environaental/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 /> i Service Code <br /> Nature of Service Request: <br /> Assigned to In V I V IL Employee # �1 Date <br /> Date Service ompleted _/ / Further Action Required: Y / N PROGRAM ELEMENT 2 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt If Check # Recvd By <br /> SUPV / / ACCT / / _ UNIT CLK _/_/_ <br />