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y SERVICE REQUEST �^R # (SERVREQ) Revised $/23/93 <br /> L�l <br /> TY ID # RECORD ID # <br /> FACILITY NAME aLiNG PARTY <br /> SITE ADDRESS <br /> CITY SC C%�' Y� CA Z I P <br /> OWNER/OPERATOR y Leo!/ S BILLING PARTY �j N <br /> DBA PHONE 01 <br /> ADDRESS (/ O v ' /��i� PHONE 02 ( ) <br /> CITY STATE ZIP <br /> FAPN # Land Use Application # <br /> i30S D i st Location Coote <br /> a <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR ` /tOOO-G 61, BILLING PARTY Y / N <br /> DBA PHONE #1 i ) <br /> MAILING ADDRESS FAX # ( ) <br /> CITY STATE 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 prepay this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes Standards, St e a eral laws. <br /> APPLICANT'S71p- <br /> TURE <br /> title- Date: �� 1 <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 /> 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: (/_ t� (/l��, Service Code <br /> Assigned to � 6 Y Employee # "' Date -/-/ <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Baid Date of Payment Payment Type Receipt # Check # Recvd By <br /> =REHS _/ / SUPV _j_/ ACCT / j��/ UNIT CLK _/__J <br />