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SERVICE REQUEST (SERVREQ) Revised 5/13/93 <br /> FACILITY ID # CRECORI) ID # rl BILLING PARTY Y / (fN) <br /> y", <br /> o l 59s� <br /> FACILITY NAME �?'k <br /> SITE ADDRESS <br /> CITY L!f` r! CACf'LIP <br /> OWNER/OPERATOR 1� V� BILLING PARTY �/ N <br /> DBA PHONE #1 ( � ) I�/- &673-5 <br /> ADDRESS I �)- i Jl! ""V PHONE #2 ( ) <br /> l <br /> ( � <br /> CITY V C � � STATEy' ZIP <br /> APN # Census --------- SOS Dist Location Code City Code ------ <br /> CONTRACTOR and/orfrafi(1u <br /> SERVICE REQUESTOR � V BILLING PARTY Y / <br /> I' - 17 <br /> DBA Scott <br /> c �1/ 1? . al/u PHONE #1 (9)() ) L -2-33 3 <br /> MAILING ADDRESS o0-e,%-dk` <br /> )n. FAX # ( 510 <br /> CITY � �e���1t��� STATE C� 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinanc C s and S oderds, State and Federal laws. PAYMENT <br /> APPLICANT'S SIGNATURE R EC F W F(%, <br /> Title: t <br /> Date: L� �I���g JUN 16 1998 <br /> SAN JOAC�UIN GOUNTr <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, oper�'tW6rti gq�\A;� of <br /> ENVIRONMI hNT�HE b AKN <br /> the property located at the above site address hereby authorize the release of any and all results, geotec n al <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 ( C <br /> Assigned to Employee # ® 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 /> REHS �/ SUPV _/ / ACCT _/ / UNIT CLK _/ / <br />