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SERVICE REQUEST 1'ERVREo) Revised 8/23/93 <br /> v <br /> FAP.ILIIY IDR RECORD ID N INVOICE N <br /> Wftl1Y NAME BILLING PARTY y / N <br /> SITE ADDRESS �C,/O 1CL.l..•GL �,C./IF-C, . <br /> CITY _ (�C1��C-C--,.� � IIP v <br /> nUNFR/OPERATOR �/ ( �l}{� Ig x-l,U--Q,Q,.LJ BILLING PARTY Y / 00 <br /> DRA r / PHONE MI <br /> q ( ) <br /> ADDRESS 3 � (� CtMA (7 >r,n_.� PHONE N2 ( ) <br /> CITY `tiY�"�- ✓�' STATE ��� ZIP <br /> rAPN-N --�Lerd Use AppU cellon N <br /> BOF Otst Location Code <br /> CONTRACTOR and/or �, <br /> SERVICE REOUESTOR -e-(,, y/, �p _ �GkC�N D,'lA�.0 CBILLING PARTY cy / N <br /> DBA PHONE N1 (d-C —ZCal <br /> MAILING ADDRESS (�`� v "I � OC-0 LL�1. FAX N/ (-CO <br /> CITY STATE �� ZIP ��S <br /> MILLING ACKNOWLEDGEMENT! 1, the undersigned weer, operator or agent of sane, acknowledge that all site and/or protect specific <br /> PIIS/ENo hourty charges associated with this facility or activity will be billed to the party Identified ss 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 CAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE I <br /> Title: Date: <br /> A111HORIZATION TO RELEASE INFORMATION! In addition to the above, when applicable, I, the owner, operator or agent of sane, of <br /> the property located at the above site address hereby authorize the release of any and sit results, geotechnical data and/or <br /> envlrormentst/site assessment information to SAN JDAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It Is available and at the sank time it 1s provided to me or my representative. <br /> z '� �—t� <br /> Nature of Service Request! Service Code ,IJ <br /> Assigned to �" v Employee N _ �l/ Date / / <br /> Date Service Completed Further Action Required! t�J / N PROGRAM ELEMENT �• � <br /> Fee Amount Amount Paid Date of Payment Payment type Receipt N Check N Recvd By <br /> RE ITS I _/ / SUPV / /_ AC&JV 1/,A/ UNIT CLK _/_/_ <br />