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SERVICE REQUEST ( SERVREQ ) Revised 8/02/93 <br /> h <br /> FACILITY ID # RECORD ID # �G - ( INVOICE # // 1 <br /> IF <br /> FACILITY NAME BILLING PARTY Y / CN) <br /> SITE ADDRESS C�,�,"��-�, n �_ Glln,,• /�[-, <br /> CITY CA 21P <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Census . . . . . . . BOS Dist Location Code City Code - - - - - - <br /> CONTRACTOR and/or <br /> SERVICE REQUEST BILLING PARTY Y �/ N <br /> DBA / C PHONE #1 ( W60 <br /> MAILING ADDRESS 8/61 ACLlZ4ck Ave FAX # I38 - 84j <br /> CITY STATE elf� ZIP % 57 <br /> BILLING ACKNOWLEDGEMENT : I , the undersigned owner , operator or agent of same , acknowledge that all site aril/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 , SStttaatt_ee and Federal laws . <br /> APPLICANT ' S SIGNATURE <br /> Title : / SSSciomate• <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 me or my representative. <br /> i <br /> Nature of Service Request : Service Code <br /> Assigned to • C Employee # �� '7,�Q Date / <br /> i <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS SUPV ACCT _/_J UNIT CLK ��_ <br />