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I <br /> SERVICE REQUEST (SERVREQ) Revised 5/13/43 <br /> FACILITY IO # RECORD ID # BILLING PART / N <br /> FACILITY NAME /`i/�_ i// S�h�U,C z or°�.C�cl # )Cro <br /> I� — -- <br /> SITE ADDRESS <br /> CITY �it-�e�/y J7/� �' ZIP <br /> OWNER/OPERATOR Z BILLING PARTY Y <br /> DBA PHONE #1 F70 <br /> ADDRESS �'U/ T �U�/ C PHONE 02 ( ) <br /> r � <br /> CITY STATE C-- /4/' ZIP ZU <br /> APN # Census --------- BOS Dist Location Code City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR =BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS FAX 0 ( ) " <br /> CITY STATE ZIP <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 bermed 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 /> AUTHORIZATION TO RELEASE INFORMATION: In additi 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: �U/,C (�/}4,41, Service Code 5a� <br /> Assigned to 4111"(,IG, L L-Ji S Employee # �� ��� 3 Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT -K �- <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS _/ / SUPV _/ / ACCT I _/ / (UNIT CLK _/ / <br />