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SERVICE REQUEST (SERVREQ) Revised 8/23/03 F ILITY ID 0 RECORD Ib N 'T" 3-3 INVOICE R tACILITY HANE v % /�Li/ X- r�o c�n4J 9� LOILLIM0 PARTY Y / N 511E ADDRESS L �� / / / w�� '�� i►1 `C``��Z Z / CITY v CA ZIP 41 v nt�NFR/OPERATOR BILLING PARTY Y / N TZ DRA PHONE k1 ADDRESS L - PHONE 02 CI1Y e 1A1E , 1 ZIP _At'N pLend Use Application N BOS hist L=onC� CONiRACTOR and/or /I SERVICE REQUESTOR 6L /tib / BILLING PARTY Y DBA ( lZ�� nI�/� =� PHONE 01 ) / MAILING ADDRESS G 17 1�P�// FAx CITYSTATE L ZIP 2 Rif-LING ACKNOWLEDGEMENT! 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific Pi1S/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. 1 niso certify that i have prepared this application erxl that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. APPLICANT'S SIGNATURE ',!� L c, Title: ��/ (r �7 -`�� iJ bate: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of game, of the property located at the above site address hereby authorize the release of any and ell results, geotechnical data and/or environmental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTN SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. Nature of Service Request: . l ✓7z Service Code Assigned to Employee M 10 Date Date Service Completed / / Further Action Required! Y / N [PROGRAM ELEMENT" Z. Z-' Fee Amount Amount Paid Date of Payment Payment Type Receipt M Check A Recvd By 5 ISS /� i3 -7 y RFHS / / SUPV / / ACtr UNIT CLK -/ /