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SERVICE REDUEST (SERVRED) Revised 5/13/43 <br /> FACILITY ID # ��� L1iJ � � RECORD ID # BILLING PARTY Y <br /> �— n <br /> FACILITY NAME P�W1 L <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 <br /> ADDRESS PHONE Y2 <br /> CITY STATE ZIP <br /> APN # Cens•.0 F•---•---- BOS Dist I I Location Code :Z City Code --•--• <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR BILLING PARTT/ G��q � /- N <br /> DBA l r r e`a pe rf��-�-. PHONE #1 ( 2�&Cj )4r <br /> MAILING ADDRESS ruX, W �AJf�N-C Il-�! FAX # ( '-(/-! <br /> i CITY STATE t/r' ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all Site and/or project specific <br /> PNS/EMD 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,;Pe work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards tate Fede lows. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: /T�9 <br /> AUTHORIZATION 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 /> envirormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon ns <br /> it is available and at the same time it is provided to me or my representative. 11 <br /> Nature of Service Request: LService Code CO/ <br /> Assigned to k Employee 5)�- s, Date �/ oZ/9_ <br /> Date Service Completed _I_/— Further Action Required: Y / N PROGRAM ELEMENT ,Leu, V&V <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �� �8 � z q3 3989' 3989 <br /> RENS I _i_/_ I SUPV �/ !(. /� ACCT _/_/_ I UNIT CLK <br /> v I <br />