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sot t.- Su vrP-kiL M\1 S-ruZ`( REFCR-V ' ml,:-s- 98-ZS <br /> PA; -e L N(-'r, l 4�� <br /> SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # l✓�I ��6� INVOICE # <br /> FACILITY NAME U-4LiAN FA'MIL`( -T);ZU_>- - BILLING PARTY Y / <br /> SITE ADDRESS t P-11l I <br /> CITY cA ZIP 95 L4Z <br /> OWNER/OPERATOR .Toe BILLING PARTY / O <br /> I�913 Jf1c�� <br /> F3R/�GOC_Ei-L RZ7 PHONE #1 <br /> ADDRESS l('��\�C f1, `�J L'L� Z PHONE #1 ( ?C y ) La - Sc-4-:-- <br /> CITY STATE ZIP <br /> [APN # Land Use Application # <br /> oil-c�C)C.)-c5z,) MScz. il~r BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR VYALSV% GV�-T I� t� BILLING PARTY / N <br /> DBA c l\!i 1` C t 11��� �- ��JCYI- PHONE #1 <br /> MAILING ADDRESS 4-N:2, f'�lA`rr�-i eY l PL.RZ� FAX # ( ) <br /> CITY STATE ZIP <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 /> 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 Fecieral laws. <br /> APPLICANT'S SIGNATURE ��[{� / (r{�(/Lli1J OCT 91998 <br /> Title: c_i�lll- �_1�<:I►�l £ Date: fin- I����� PUt' <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 <br /> me or my representative. <br /> Nature of Service Request: G 1 v�lt4i� Il VI (Jl�`\ Service Code <br /> -n <br /> Assigned to < y� ���1 1 Employee # C 2, Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> FeeAmountAmount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ( <br /> C)I l g I q 8 V I�2 IPJ <br /> REHS ��_/v/ /� SUPV _/ / ACCT _/ / UNIT CLK _/_� <br />