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�,.. SERVICE REQUEST `Ve (SERVREQ) Revised 5/13/93 <br /> FACILITY ID # RECORD ID # LING PARTY Y / N <br /> NAME LI/P -T\ `^ J CY, )tJ G INC- <br /> FACILITY <br /> SITE ADDRESS <br /> CITY • NCA ZIP <br /> I �pp � 10 C7 <br /> BILLING PARTY (�y�Y <br /> DBA (� 1 ,� , n n r PHONE #1 (2a c ) SOK- /J y <br /> ADDRESS _*r�,�IR-1 V V1 1 I�F 1"I!� AVC. Q a PHONE #2 ( ) <br /> CITY S V ` Y—�+'J STATE l ` r ZIP /5 5� n L4 <br /> APN # Census --------- SOS Dist Location Code City Code ------ <br /> CONTRACTOR and/or /--� <br /> SERVICE REQUESTOR .�c� — k.icuAYr)1�/ � BILLING PARTY <br /> DBA ^-a/- Y W �_ __t_l�/_,` PHONE #1 (;;)(39y/ ,say- 53 <br /> MAILING ADDRESS ID 1 -7 �6b , 7 -s V/ FAX # FY v i )�(/- C)S 03 <br /> y0 <br /> V <br /> CITY ni 1 0 A STATE Cl ZIP �S3 S- <br /> BILLING <br /> BILLING ACKNOWLEDGEMENT: 1, the Undersigned owner, operator or agent of same, acknowledge RTA 6Y1fi/s® <br /> ENTd/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the parF4 E!J"Dthe BILLING PARTY on <br /> Page 1 of this form. <br /> F 0 7 1' <br /> I also certify that 1 have prepared this application and that the work to be performed acc9q,"ce with all SAN <br /> JOAQU[N COUNTY OrdinanceCodes apd Standards, State and Federal laws. PU13LIC HEAL i H `:I F'V CES <br /> I /l itENVIRON�,IENTAL HEAL?H DIVISION <br /> APPLICANT'S SIGNATURE(/�: A Ih O`A L`� 'IL�YI/�V)� l /��/ <br /> Title- t.-t�. L Q 0,0 Date- '+� — 5— 1 7 <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 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: O ti � I Service Code <br /> Assigned to Jn1A"� Employee # in Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> a I I <br /> REHS _/ / SUPV _/_/ ACCT _/ / UNIT CLK <br /> 1 <br />