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�- SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY 1D # RECORD ID # I INVOICE # <br /> FACILITY NAME tp1y,:5 C'.-- BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY Sin C k I-VA7CA ZIP <br /> OWNER/OPERATOR IV' L X7%5 C /�ri�nSe�-1 BILLING PARTY Y / N <br /> DBA �Ct/�1pSP� /�� Jio�r� l PHONE #1 ( k)? Y0-S <br /> ADDRESS gsy0 �c k w ��l f�� PHONE #2 ( ) <br /> CITY STU C 7�0 STATE CZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or E'lclSse� S��1�nr,��Z yr l�SS C7C <br /> SERVICE REQUESTOR AL e / o - //n C� 2icSU�7 r� frSSO c. �vtC BILLING PARTY cy—)/ N <br /> DBA GC'0 c-L+ vircc.DSLZAPHONE #1 ( �L ) `/YC)d(P d <br /> 11 <br /> MAILING ADDRESS J 13 /1- U. 0,< Clr`{Y FAX # (—)-- <br /> CITY <br /> ) -CITY S /-D STATE C-1- ZIP gS- y / - 08-Yy <br /> BILLING ACKNOWLEDGEMENT: 1, 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 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 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 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 me or my representative. <br /> Nature of Service Request: Service Code <br /> Assigned to 0 Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT O <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS / / SUPV _/ / ACCT / ` /� UNIT CLK _/ / <br />