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- ' SERVICE REQUEST • (SERVREO) Revised 5/13/93 . <br /> FAC ILIT"0 V 3 RECORD ID # � BILLING PARTY Y <br /> f6 <br /> e / <br /> ".ti._. FACILITY NAME �1,1 LaIn d�o0l <br /> E SITE ADDRESS U 141 <br /> �,. CITY �'Y- L iVn CA Zip ICJ r�—� C7 <br /> { <br /> ` <br /> OWNER/OPERATOR <br /> n V-S - BILLING PARTY / N <br /> i <br /> f <br /> I DBA I PHONE #1 ( > <br /> f / <br /> f ADDRESS <br /> PHONE sz l <br /> ( Su > $�1Z- 9(P <br /> CITY ,Z(l t^^PIC% STATE 21P ��� D2�1 <br /> APN # Census •----•--- BOS Dist Location Code City Code ---•^ <br /> CONTRACTOR and/or1` /t <br /> SERVICE REQUESTOR S(,0'h C-e>ys\an BILLING PARTY Y ff / <br /> DBA PHONE 01 C-20 p2,-5�s <br /> MAILING ADDRESS \ 1` 1 �����\ `\"e FAX 8 (sic, <br /> t f q\ <br /> iCITY ` Jz STATE 111 ZIP 5 TT <br /> BILLING ACKNOWLEDGEMENT: I, 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 in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance ode rid Standar at laws. <br /> i <br /> APPLICANT'S SIGNATURE <br /> t <br /> I <br /> Title: <br /> Date: U � � <br /> i 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 /> envirorrtiental/Site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> I it is available and at the sane time it is provided to me or my representative. cJ� <br /> Service Code �Q6 <br /> Nature of Service Request: <br /> r <br /> Assigned to // Employee ITI loyee # D <br /> K <br /> / / <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT ;Z J 00' <br /> ' <br /> A <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> i <br /> a <br /> l �1� UNIT CLK <br /> RENS Clr7/�/ aSUPV _/_/_ ACCF _/_J__ <br />