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v ( ("t"c � <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/43 <br /> FACILITY ID # RECORD ID # - INVOICE # ✓ � � <br /> FACILITY NAME `- � _ LBILLING PARTY Y f N <br /> SITE ADDRESS <br /> CITY r C'/� CA ZIP <br /> OWNER/OPERATOR <br /> C BILLING PARTY T / <br /> DBA / c RC <br /> PHONE #1 ( �! 3)_�,-ADDRESS t/ Cy� PHONE #2 ( ) <br /> r� 7 <br /> CITY �� STATE <br /> APN # Land Use Application # <br /> IF FB�OS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR C/� ' !Lam" Lam[/•�E�' BILLING PARTY Y / N <br /> DBA PHONE #1 _) <br /> MAILING ADDRESS Cil FAX # <br /> CITY '� STATR�� ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> I also certify that I have prepared this application and that the work to be performed will be done in accordanee,Wi;th all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. <br /> APPLICANT'S SIGNATURE 4�'1/ <br /> Title: G iEE-1VWA Z- Date: Pit <br /> �- <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 timeitis provided to me or my representative. <br /> Nature of Service Request: -o Service Code <br /> Assigned to Employee # 0 Jr Date <br /> Date Service Completed / ! 4 /07 Further Action Required. Y / N [PROGRAM ELEMENT Q {� <br /> Fee Amount *vaunt Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RE HS C / SUPV / / ACCT 1 / UNIT CLK �/� <br />