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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br />FACILITY ID #I I RECORD ID # I (")'d q �(( I INVOICE # I Dc 37-3R <br />FACILITY NAME f,�/ ze=T1� BILLING PARTY Y / N <br />SITE ADDRESS %AkAM a&� <br />CITY CA ZIP <br />OWNER/OPERATOR <br />DBA <br />BILLING PARTY Y / N <br />PHONE #1 ( ) - <br />ADDRESS��- /r / WHONE #2 <br />CITY/`�J�� �� STATE _,a::7, ZIP <br />FAPN # Land Use Application # <br />BOS Dist Location Code <br />CONTRACTOR and/or A - <br />SERVICE REQUESTOR ��y.G U.J 1`�U�l tP� BILLING PARTY Y / N <br />DBA PHONE #1 ( ,— <br />MAILING ADDRESS `--, N. �22", x+ -A4'-- FAX # ( ) - <br />CITY i) lA 06c,-Gtli STATE _&Yer- 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 Federal laws. PX' EN7 <br />APPLICANT'S SIGNATURE <br />DEC <br />Titl <br />Date: <br />SAN JUA?UIV CCJNT"' <br />U8L!C HE:hI.TH SERVICES <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operatoryeW�p !W.UNWj14"V!SiON <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: <br />Assigned to _� i f —.gy:j, Employee # <br />Date Service Completed / / <br />Service Code <br />Date / / <br />Further Action Required: Y / N I PROGRAM ELEMENTy ,�C;Z: a <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check #Recvd <br />By <br />7%:3, , <br />2� <br />-.Y_1 Z-1 ? <br />a44 -k- <br />REHS <br />/_j2 / 1'(--- <br />SUPV <br />I/_/ ACCT 'Z- / '4 / J UNIT CLK <br />I <br />''W -- _.1 - -I --w- <br />_ __ _ <br />