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SERVICE REoUES1 (SERVREQ) Revised 8/23/9 <br /> L—ArILITY ID g RECORD ID M�r <br /> ICE 9 %17 <br /> r A C I L I T Y NAME /�`f�C��bh �J"t2�' ^ l - [t�j (f I"w <br /> SITE ADDRESS C/7`fi <br /> CITYz&y/ 9` ZIP V 1 <br /> (UIFR/OPERATOR 1` (� �d� �J�►1C BILLING PARTY / N <br /> DBA PHONE 01 <br /> ADDRESS h�5' '!�! `I'11it Q/aT ' PHONE 02 ( ) <br /> CITY d^ D'�� STATE ZIP C�,z <br /> APN M —Lend Use Application g <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SFRVICE REOUESTOR BILLING PAR 1Y Y / N <br /> DBA PHONE 01 <br /> MAILING ADDRESS FAX 0 ( ) <br /> CITY STATE ZIP <br /> RII_LING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site end/or project specific <br /> PHS/END 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 ell SAN <br /> JOAOUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title• Date, <br /> AIItHORiZATION 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 date and/or <br /> environmental/site assessment information to SAN JOAOUIN 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 /> ,/�J /p <br /> Nature of Service Request: / , CL Service Code <br /> Assigned to yIC- "I � JIE�/y� Employee N (L��,k bete <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> SUPV _/ / Am �/ /� UNIT CLK _/ / <br />