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'�R # <br /> SERVICE REQUEST /93 <br /> i <br /> Q(� (SERVREG}) Revised 8 <br /> FACILITY ID # RECORD ID # ,(' INVOICE # <br /> n <br /> FACILITY NAME NV <br /> SITE ADDRESS a� /�t �L 6 fZD <br /> CITY p4/tJ CA ZIP <br /> OWNER/OPERATOR ` ILLING PARTYY / N <br /> DBA PHONE 01 ('✓(O <br /> ADDRESS PHONE #2 (�(/ } J '�- <br /> CITY �ti� STATE - - ZIP <br /> APN # Land Use Application # <br /> IF BOS Dist Location Code <br /> CONTRACTOR and/or <br /> $FRVIRF RFRNEBT®R RIL6ING PARTY Y / <br /> DBA Gd PHONE #1 (zc ), - ' -3 <br /> MAILING ADDRESS ` �f c1 �T FAX <br /> CITY 1���� �?L� STATE ZIP <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 1 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 Standards, state and Federal laws. <br /> C <br /> zt4al APPLICANT'S SIGNATURE <br /> ys <br /> Title: ,�T'Qd27j 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 ail results, geotechnical data and/or <br /> envirormentai/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. �1 <br /> Nature of Service Request: - L( Service Code /` 2— <br /> Assigned <br /> Assigned to (� L .^-LTErtployee # 1 Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT o�� •� '" <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> /93 <br /> SUPV / / ACCT UNiT CLK _/ / <br />