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SERVICE REQUEST A& (SERVREO) Revised 5/13/93 <br /> FACILITY ID # RECORD ID # <br /> AM It <br /> FACILITY NAME I # — <br /> SITE ADDRESS I Lj L I tj 7a <br /> CITY I \� C'�(() aV CA ZIP J <br /> OWNER/OPERATOR F�1�IV J C'1�� }�° ICY - C(CT BILLING PARTY / Y�)/ N <br /> DBA ��� C Q i r) PHONE #1 ( S�L) ) <br /> ADDRESS / C� V1 ) �7�C_.ij'\f RTLS, (`J R VSE PHONE #2 ( <br /> CITY �� [-#�\L-Pr"0 STATE () ZIP C L/ ( L�) 1 <br /> APN # Census --------- <br /> ------- BOS Dist Location Code City Code -- - <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR BILLING PARTY Y / 1� <br /> DBA `` PHONE #1 <br /> MAILING ADDRESS l -J 12 -7 FAX # ( ) <br /> CITY /A OOF—ST-D STATE ZIP S <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site a 'oi�_ 1* `ect specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as' ,G PARTY on <br /> Page 1 of this form. <br /> Sl IV jr) <br /> I also certify that I have prepared this application and that the work to be performed wilfl^ � elsryjAJ�dr��9C8;Wi,1 all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and eral laws vn��`I�1Ur�� T��: ViC!'ry <br /> �!V S � <br /> APPLICANT'S SIGNATURE G n <br /> Title: Y7vf\ e/�LQ.1 Date: I a f <br /> o� <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 /> Nature of Service Request: �5 Service Code <br /> Assigned to � r(}� &-gig Employee # / Date <br /> Date Service Completed / / Further Action Required: Y / N FP <br /> ROGRAM ELEMENT 3 (i <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ry <br /> RENS _/ / SUPV _/ / ACCT /1! / UNIT CLK _/ / <br />