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SERVICE REQUEST CEH 00 613 Revised 8/23/93 <br /> RECDRD ID # ! 1 b INVOICE # �a$ <br /> FACILITY 1D # <br /> FACILITNAME BILLING PARTY Y / N <br /> Y 4� / <br /> SITE ADDRESS <br /> CITY ���'' CA ZIP <br /> �y(I G `, BILLING PARTY Y / N <br /> OWNER/OPERATOR <br /> F _ PHONE #1 ( ) <br /> DBA <br /> ADDRESS PHONE #2 ( ) -��— <br /> CITY STATE ZIP <br /> APN # Land Use ApplicationF # <br /> FBOS Dist Location Code <br /> CONTRACTOR and/or � <br /> SERVICE REQUESTOR BILLING PARTY Y / N <br /> DBA I PHONE #1 ( ) <br /> MAILING ADDRESS / { / ( FAX # <br /> CITY lSS �/ _ STATE ZIP <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. J' l <br /> APPLICANT'S SIGNATURE <br /> Title: (I/P QC Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of some, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical date 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 Se vice Request: 912VZ2 Service Code +�Z <br /> T <br /> Assigned to Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> to tC� �u,y,� <br /> ES / / SUPV `/ / ACCT _/ / UNIT CLK / / <br />