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SERVICE REQUEST <br /> LEH 00 61) Revised 8/23/93 <br /> RECORD ID # INVOICE <br /> FACILITY ID # jJ <br /> FACILITY NAME nR);(-Zr gF&EA( �� BILLING PARTY Y / N <br /> SITE ADDRESS I2�32 VAN ALLEN } G <br /> CITY f Ss C-- c� &QAJ CA ZIP /�� -2—c? <br /> OWNER/OPERATOR K ", l� BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS <br /> PHONE #2 ( ) <br /> CITY /�{��,// JSTATE ZIP <br /> APN # 5 �s Application o / <br /> _ BOS Dist Location Code <br /> CONTRACTOR and/or ,/ l/ , <br /> SERVICE REOUESTOR 1/ n r S�E / BILLING PARTY Y / N <br /> DBA ( U A L I Z1/ 0ONT)20 IN SPC—C7 W/O PHONE #1 (�) <br /> FLAILING ADDRESS i�l �� /V rF7 rk7C LL' FAX # ( ) <br /> CITY STATE q 21P / fl 32 <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 will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in Acpqr�,dap a with all SAN <br /> 11 <br /> JOAQUIN COUNTY Ordinance Codes and t ards, State eral laws. o A Yrivr <br /> RErr�VR'•r <br /> APPLICANT'S SIGNATURE <br /> V r J A <br /> Title: I Date: <br /> LNVIRONMJNTA�, ?'H SFR VI_'[,, <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, opera or o 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 /> enviroraentaL/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: �.-,'/ ' u/' l Service Code <br /> say <br /> Assigned to ` Employee # V ��f' Date <br /> Date Service Completed 1 I /_L0 /_9L5 Further Action Required: Y / N PROGRAM ELEMENT e`"d' 7 Z- <br /> Fee Amount Amount Paid Dale of Payment Payment Type Receipt # Check # Recvd By <br /> •d0 /yf+ , OD � �- D-� �/ X569 �,�,i <br /> REHS / / C SUPV �/ /� ACCT i / ��/ �} UNIT CLK / /_ <br />