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SERVICE REQUEST (SERVREO) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # 6 O INVOICE # <br /> FACILITY NAME -!./ 'e f) /7 Ga✓/ / 011�l BILLING PARTY Y <br /> 7 / CJ <br /> SITE ADDRESS / Z S 0 F-C• k DD d L'l J 2I 'P IQOI_ <br /> CITY N�� /I O CA ZIP / Sz�C) <br /> MS q `t - 3 � <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 <br /> CITY _ STATE ZIP <br /> p AD/ =J D O 7� Land Use Application # - [ I T� <br /> I 7 BOS Disf ILocatton Code <br /> CONTRACTOR and/or ! <br /> SERVICE REDUESTOR ECat-yq cit r • 5w,%V "' , C BILLING PARTY <br /> DBA GI_ VK, PHONE #1 ( ) <br /> MAILING ADDRESS -6- 35-5- (Sclav-� KayA-GL,_ RJ _ FAX # ( ) <br /> CITY S c-Ll- STATE 0 X ZIP <br /> Cao L931-1 ,3 7s' <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 St rdi State and F rat laws. <br /> L i <br /> 44..p i <br /> APPLICANT'S SIGNATURE C�U -( <br /> C-I V I L (�--/JG pe- Date: , Z ;L 9 Uh �+ CW�LNEAL H <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: !�-is-Jc� � r-��_� rr. _ Service Code <br /> Assigned to ) Employee # Date <br /> Date Service Completed JgIL/ ` /� Further Action Required: Y / 11, PROGRAM ELEMENTd— <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> s �a LI "far.K <br /> REHS _/ / SUPV _/_/_ ACCT _/_/ UNIT CLK <br />