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SERVICE REQUEST `r (EH 00 61) Revised 8/23/93 <br /> FACILITY ID J RECORD ID # INVOICE # r/ <br /> FACILITY NAME /�irr,i .�`z�-�,., .,f� � <br /> BILLING PARTY J / N <br /> SITE ADDRESS ZZ 5S20 <br /> CITY CA zip 93276 <br /> OWNER/OPERATOR Sa .•. a r ¢ G e�C <br /> BILLING PARTY Y / N <br /> DBA PHONE #1 (ZO�, )-607- Z��Q <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> FAPN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVILE REOUESTOR � Sv ` � � / p/� � � BILLING PARTY Y <br /> DBA PHONE #1 ( ) '� <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 identifoxy "PILLING PARTY on <br /> Ewl <br /> Page 1 of this form. PF(lr_vlIr t1 <br /> I also certify that I have prepared this application and that the work to be performed will be do@0-J 44ciftwith all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> .,( SAN JOAQUIN COUNTY <br /> APPLICANT'S SIGNATURE <br /> tPd R p11111EALTH D!VISI N <br /> Title: Date: �9S 07 <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 JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the sametime <br /> (it is provided to (me opr�—my repprrese(nnttative. <br /> Nature of Service Request: 6e N2 a i:�_Xn\LH.X.(iC.(n \ x1.LkJL� f( Service Code 5c�,� <br /> Assigned to �o�p Z Employee # v> 7S ).J Date <br /> Date Service Completed _/_/_ Further Action Required: Y / N PROGRAM ELEMENT 7 <br /> fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 5 u�� ;�,-r; ✓ i�; k6u�,, <br /> REHS _/ /_ SUPV _/ /_ ACCT _/_/ UNIT CLK —/----J— <br />