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SERVICE KEQUEBt (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # � ECORD�ID # <br /> FACILITY NAME ,:24 �C BILLING PARTY Y / N <br /> SITE ADDRESS � � /frit ✓� �/aj� <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA .J PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATF _ _ ZIP <br /> FAPN # Land Use Application # —--- — <br /> fj� 9r /� BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR D _ BILLING PARTY Y / N <br /> DBA y —_ <br /> / PHONE #1 <br /> MAILING ADDRESS <br /> FAX # ( ) <br /> CITY ? ^ ✓ / <br /> <e��l 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 �,iil be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> 1 also certify that 1 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 law,. <br /> APPLICANT'S SIGNATURE <br /> Title: 1 �� <br /> Date: �2�IG1 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the ahov-, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the -etease 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 Regquues SrT1( ({( i 1 Service Code a Z <br /> Assigned to v Employee # _ f/ Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT �• Z <br /> Fee Amount Amount Paid Date of Payment Payment type Receipt # Check # Recvd By <br /> is I _/ / SUPV _/ / ACCT / / UNIT CLK <br /> .L <br />