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• SERVICE REQUEST <br /> /13/93 <br /> RECORD <br /> FACILITY ID # RECORD ID # ING PARTY ,y•,/ N � <br /> • FACILITY NAME r/ /i''� SQ "S -_! -AC i/ tt <br /> SITE ADDRESS 1/// Z� �! , /(�r —`-� SIV # �� <br /> CITY _/`(7 t� / CA ZIPI1 <br /> OWNER/OPERATOR. `..jl1G" V('� 'k�.(�1'j BILLING 77PARTY / N <br /> DBA PHONE #1 <br /> ADDRESS <br /> PHONE #2 (Z—L'Y <br /> CITY f STATEe-�4 ZIP 1-4�Z Z((D <br /> APN # Census --------- BOS Dist Location Cade City Code ---••- <br /> <, CONTRACTOR .and/or ) <br /> SERVICE REDUESiOR U[.{�.71.;iC7?nI7., i�. L—,`l �.. / �. <br /> w BILLING PARTY <br /> DBA ''�� /� PHONE #1 ( ,C% ) /Ee -//���J� <br /> MAILING ADDRESS �L^^'' 4I x SCJ FAX # ( `U ' )e/e- - <br /> F? <br /> CITY�i�C-�L�T-V STATE _ ZIP (0 �G <br /> • <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. \f <br /> I also certify that I have prepaiired\thifappgication and that the work to be performed will be done in accordance with all SAN <br /> JOAOUIN COUNTY OrdinaroeTCrodes arf�STa Ards State Arid Federal laws. <br /> f <br /> APPLICANT'S SIGNATURE <br /> Tit let -�-/✓_ C <br /> Date: L '/-S I7 � <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 ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request:✓ / /�� Service Code V,3 7 <br /> Assigned to ELI(!- /.e�(JGNi1 Ertployee # r6, QY Datec-- <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT ✓ J <br /> • Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS _/_/_ SUPV _/_/_ ACCT �� i�../ / .r�� UNIT CLK / / <br />