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_------ _ SERVICE REQUEST— (SERVREO) Revised 5/13/93 <br /> FACILITY 10 # j /� :ORD IO # LLING PARTY <br /> FACILITY NAME <br /> SITE ADDRESS <br /> CITY G 0" CA zIP <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> i <br /> DBA PHONE #1 ( ) <br /> ADDRESS �C� o• / W(�� PHONE 92 <br /> CITY GGt ►�. STATE (-I ZIP %`JZGA- <br /> APH # Census --------- SOS Dist location Code , City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR JIyL/ � ���� BILLING PARTY / N <br /> DSA PHONE NI ( <br /> MAILING ADDRESS / 'V I vVl` +��Z/ FAX # ( ) <br /> CITY //Wl � STATE lii ( ZIP 9 <br /> BILLINGACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/E HO 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 1 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 Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> — <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 /> environnental/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 Reqs t• I�UU�l Service Code. W <br /> Assigned to � Employee #: e9(D '� Date: ��-ZZ <br /> Date Service Completer!. Further Action Required: A)ax-e= <br /> PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RE HS / / SUPV / ZZ ACCT _/_� UNIT CLK <br /> � a <br />