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SERVICE REQUEST I n JE�^ ,� /93 <br />F <br />CILITY ID # RECORD ID # INVOICE # <br />FACTIITY NAME <br />SITE ADDRESS <br />i CA Z I P�4� <br />rxJNFR/OPERATOR O Ci >7 JIZ D U r ! BILLING PARTY Y / N <br />DBA /%� Y L V PHONE #1 G <br />CITY�-r�� Jif e � STATE 7 ZIP CJ S� D 6 <br />F <br />APN # Land Use Application # <br />IBOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR C- r �-s ) y o /to y BILLING PARTY Y <br />DBA S (� I/Vl P/ .S c�L O V Q PHONE #1 - <br />II a o -a 9 <br />t V— <br />MAILING ADDRESS � w06d _ FAX <br />CITY STATE CZIP <br />713-(38/ <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS/FHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />Paqe 1 of this form. <br />I alto 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 Standards, State and Federal laws. <br />AFPLICANT'S SIGNATURE : G V'' / <br />Title: 1,.1 2 U -% r. e Y' Dater <br />s <br />AI)THORIZATION 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: '�� 5 Service Code <br />A-zcigned to Employee # Date —/—/ <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT�' Q <br />Fee Amount <br />Amount Paid Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />v ��?jG">� <br />RENSI _/ / I SUPV I _/_^/___ I ACCT / <br />I �'11 <br />Tr (UNIT CLK <br />—/ .� L: <br />ti <br />IG <br />