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SERVICE REQUEST (SERVREQ) Revised 5/13/93 <br /> FACILITY ID # RECORD ID # BILLING PARTY Y / <br /> FACILITY NAME TOWN & COUNTRY HAY & FEED ID <br /> # &P&4.�- <br /> 4245 E. MAIN STREET #SITE ADDRESS CITY STOCKTON CA zip 95215 # ... <br /> my ji X777 <br /> OWNER/OPERATOR SACK FRANCISCO -e Y LY / N <br /> DBA NA PHONE #1 (703 )�7 Q 5372 <br /> ADDRESS 8341 ORANGE COl1RT PHONE 92 ( ) <br /> CITY AI EXANDRIA STATE VIRGINIAzIP 22309 <br /> APN # Census --------- BOB Dist Location Code City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR FAI (^nN FNFRnyBILLING PARTY Y / 8 <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS P.n. Rna' 1257 FAX # <br /> CITY STnrao1pl STATE EA ZIP 95,%011-1957 <br /> i <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 Codes and Sta"rds, State and Federal laws. <br /> APPLICANT'S SIGNATURE '.Lt fi --0 <br /> Title: PROPERTY R Date: <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 intormati on to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it/ids provided to me or my representative. <br /> Nature of Service Request: `11(k Q O/no JQ L Service Code <br /> Assigned to Employee # — .. 5,' Date <br /> Date Service Completed / / Further Action Required: Y / H PROGRAM ELEMENT <br /> }p�Fee Amount Amount Paid Date/of Payment Payment Type Receipt # Check # Recvd By <br /> REHS _/_/_ SUPV _/_/_ ACCT / / UNIT CLK _/_/ <br />