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SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> FACILITY ID N RECORD ID N INVOICE N <br /> FACILITY NAME 1l` Y I L'�' i� ' ji% BILLING PARTY V <br /> SITE ADDRESS vC 1 -f U �K. I I� II—VI—I. UJ <br /> CITY l� ! ZIP ' <br /> 004FR/OrERATOR I'I�F4 /"� ���lC BILLING PARTYj / N <br /> DAA PHONE Ni <br /> ADDRESS a S L�' T'4LlI� _ PHONE #2 ( ) <br /> CITY �f�'t-L' STATE ��/."� ' ZIP - 3� <br /> F <br /> APN N F <br /> and Use Applicatiai # <br /> FRO�Sl)ist Location Code <br /> CONTRACTOR and/or <br /> SFRvIr.E REQUESTOR BILLING PARTY Y / N <br /> DBA PHONE 01 ( ) <br /> MAILING ADDRESS FAX N ( ) <br /> CITY STATE ZIP <br /> PILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site end/or project specific <br /> PilS/ENO hominy charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> pogo 1 of this form. <br /> I also certify that 1 hove prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes end Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION! In addition to the above, when applicable, 1, the owner, operator or agent of acme, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirormentat/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon an <br /> it is available end at the same timeItIs provided to me or my representative. } <br /> Heture of Service Request: L� f�k / �t✓✓161-A 0 I"yLt Service Code O� <br /> Assigned to L� �f� 1� Li7v (l Employee N Date <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 /> 7b Z 9 13 70 <br /> ACCT __/ /��` UNIT <br />