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SERVICE REQUEST (SERVREQ) Revised 5/13/93 <br /> ++ FACILITY ID # RECORD ID 9BILLINGA/h2 PARTY <br /> y <br /> FACILITY NAME <br /> SITE ADDRESS /�J �lJ� �• C, /Z�� r 55 <br /> CITY CA ZIP <br /> R ERATOR �C BIIIING PARTY Y / N <br /> DBA v PHCNE 41 ( ) <br /> ADDRESS t5' /l/ PHONE 02 ( ) <br /> CITY TATE(� ZIP <br /> APN N Census -----•--- DOS Dist Location Code City Code CONTRAC <br /> T /or <br /> /or BILLING PARTY Y / N <br /> 08A `- 7 A>� �y PHONE X1 (�)ly - -21 <br /> MAILING ADDRESS - <br /> CITY // aeZl STATE ZIP ( h <br /> vI , <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHO 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. i VI <br /> I also certify that I have prepared this application and that work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title• / Date: <br /> AUTHORIZATION TO RELEAS, N <br /> IFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property Lost-'e8-at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmentat%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: C� — C-/7 Service Code: f�Ly <br /> Assigned to Employee 0: Date: <br /> Date Service Complet <br /> ed: <br /> Further Action Required: <br /> PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 4 Check Recvd By <br /> REHS _/ / SUPV _/_J ACCT _/_, UNIT CLK _/_� <br />