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SERVICE REQUEST <br /> 1 <br /> FACILITY ID # RECORD ID # <br /> BIL <br /> /T/. - �/ <br /> FACILITY NAME � �/(r/ � <br /> 14 <br /> SITE ADDRESS <br /> CITY CA ZIP ---- - <br /> OWNER/OPERATOR <br /> BILLING PARTY Y / N <br /> DBA PHONE #1 <br /> 1. <br /> ADDRESS <br /> PHONE #2 ( ) <br /> CITY STATE <br /> ZIP <br /> APN # Census --------- BOS Dist Location Code <br /> City Code ----- <br /> C TRACTOR and/or <br /> SERVICE REOUE STOR /I'/' [^/� 4f�L /� /'^r�iy BILLING PARTY / Y )/ N <br /> DBA _ - '4 PHONE #1 7� <br /> MAILING ADDRESS //J7 A�,Gp')�(/) - /�/t,rjJ' G �✓ � FAX # ( ) <br /> CITY STATE ell 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 /> 1 also certify that I have prepared this application and that the Work to be performed will be done in accordance with all N <br /> JOAQUIN COUNTY Ordinance Codes and Standards,,,"e and Federal laws. /' <br /> /' <br /> cam, /l lsY6 <br /> APPLICANT'S <br /> SIGNATURE <br /> Title: Mg 3 1� e� Date: / / / ✓" yp" /" )' <br /> AUTHORIZATION 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 data and/or <br /> environmental/site assessment information to SAN JOAQUI14 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 ServiccGee,Request: �) Service Code <br /> ,Assigned to v✓ ` � Employee # v Date �r� <br /> Date Service Completed _/ / Further Action Required:�/ N PROGRAM ELEMENT s( <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 77 <br /> i�3 s C> .� rctc So 3 <br /> REHS <br /> _/_/_ SUPV _/ /_ ACCT UNIT CLK <br />