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SERVICE REQUEST C� C��"'r� (SERVREQ) Revised 8/02/93 <br /> FACILITY ID # RECORD ID INVOICE # <br /> FACILITY NAME vV QL/{-�7I e— /V( ✓�/• e5 t BILLING PARTY Y / N <br /> SITE ADDRESS S262- <br /> 2 6 2L W, L Anne <br /> ! did '?-S-376 Q <br /> CITY rUC✓ CA zip -(5376 <br /> DWNER/OPERATOR S !QIP_ as above- BILLING PARTY Y / N <br /> DBA PHONE #1 ( 43- ZOZ 1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Census --------- SOS Dist Location Code City Code - - <br /> CONTRACTOR and/or f <br /> SERVICE REQUESTOR SleAfr/ec1 Er/q//7e�r//JG� �1�j�, BILLING PARTY Y J N <br /> DBA PHONE #1 <br /> MAILING ADDRESS 464S- Coroado Ave p FAX # ( / ) 942 - 021 4 w <br /> CITY StOC STATE ZIP <br /> K <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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 SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal taws. <br /> APPLICANT'S SIGNATURE <br /> Title: ' I Q el-7 / Date: U <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 same time it is provided to meor my representative. <br /> 1 <br /> Nature of Service Request: PL'YCO/ ILIO/') 7-es/l 2 m C rhe / Service Code 5 �2 <br /> Assigned to Employee # C Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT �� <br /> Fee Amount Mount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS _/ / SUPV _/� ACCT _/ / UNIT CLK _/_J <br />