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SERVICE REQUEST (SERVREQ) Revised 8/23/43 <br /> FACILITY ID # RECORD ID # INVOICE / <br /> (� 1 FB <br /> ILLING PARTY Y / N <br /> FACILITY NAME b p <br /> SITE ADDRESS ?� C' / L�JIV f Y <br /> CITY _ 1 ���1 J CA ZIP <br /> OWNER/OPERATOR Tyr, i BILLING PARTY Y / N <br /> DBA PHONE 01 ( ) <br /> PHONE #2 ( ) <br /> ADDRESS <br /> CITY STATE ZIP <br /> APN # Land Use ApplicationF F # <br /> Loc <br /> BOS Dist ation Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR _` BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS FAX # ( ) <br /> CITY STATE ZIP <br /> 4 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 Standards, State and Federa' laws. <br /> APPLICANT'S SIGNATURE <br /> Title: ^ Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the ab-r 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: _„1, Service Code <br /> Assigned to Employee <br /> Date Service Completed / / Further Act on Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPVIACCT _J UNIT CLK <br /> �J <br />