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R,k-P- K , RVI o�o�aa - <br /> _ • SERVICE REQUEST • (SERVREO) Revised 5/13/93 <br /> r <br /> FACILIT3 RECORDID # �� BILLING PARTY Y / (N <br /> FACILITY NAME a,,1?):1 �11QOD`IP�� <br /> SITE ADDRESS 7 Lf, (( � (—C i..k q ` <br /> CITY ���C/`C1V>n CA ZIP ICJcf.� 0 <br /> OWNER/OPERATOR C4.,.:�(-G1 U'S BILLING PARTY Y / N <br /> DBA 4 , PHONE #1 ( ) <br /> ADDRESS `bo� � .-( lA ,ti <br /> n: ^ Y PHONE #2 ( StO <br /> C <br /> CITY &A ` ay"A"N STATE �_ ZIP <br /> APN # Census --------- BOS Dist Location Cade City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR �L�'T1 CONS' QW� BILLING PARTY Y / N <br /> DBA 11 PHONE 11 ( 0O23�S <br /> MAILING ADDRESS C ��`� 'l\ �o.^,�� \4. � FAX <br /> CITY STATE (S1 ZIP Ci�S� t <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all sI 3fN1I� t specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the party identified'As�ld1PARTY on <br /> Page 1 of this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be dmgryn a orda c�`(/th all SAN <br /> JOAOUIN COUNTY Ordinance ode nd Standar nal laws. ENVIg0NWN�C-f CT)O NI�, <br /> APPLICANT'S SIGNATURE ) �� <br /> Title: Date: <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 data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRCWENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided <br /> _.ptoo me ormmy representative. <br /> Nature of Service Request: �11 XIMC:t Service Code �7r5 <br /> Assigned to Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 3 a <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �23y. !. 354,7N7 4 <br /> 9 It <br /> RENS (Al�/�� SUPV _/_/_ ACCT / i f/l /o� UNIT CLK _/_/_ <br />