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SERVICE REQUEST CEN 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME CI I 1� ` / BILLING PARTY Y.- <br /> SITE ADDRESS 3Z-yZ= �. lAAMt-" �iZ- <br /> CITY CA ZIP <br /> OWNER/OPERATOR I 5� l- II�CQ'I��`TTI C'i BILLING PARTY Y / N <br /> DBA _(���IZGIl3 F•� PHONE #1 ( Wfi )5'5-8 - jaiz- <br /> ADDRESS IlA / �'cDVCII��j -- PHONE #2 (4�)* ZSS� <br /> +46 <br /> CITY S CAZAMt;4 IV STATE C► ZIP <br /> APN # Land Use,Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR. —14.k- 1' l�'�u�I+1 ( '•I�L� bigs1GT)4 P-0y )� P 1 BILLING PARTY 6 / N <br /> DBA PHONE #1 ( )�D 03 <br /> MAILING ADDRESS. tE FAX # ( 1.0:.. �.UtkJ� <br /> CITY S VaL1?i4F'l�L'y q <br /> STATE ,G� ZIP <br /> BILLING ACKNOWLEDGEMENT: 1,+ the undersigned owner, operator or agent of same, acknowledge that alt, site•aid/or project. specific <br /> PHS/EHD hourly charges associated with this facility or activity wilt 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 witl be done in accordance with alt <br /> JOAQUIN COUNTY Ordinance Codes' Standards; State and Federal laws. <br /> APPLICANTS SIGNATURE <br /> Titte: l-�1'l�l� 'jl Date: $ <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 att results, geotechnical data and/or <br /> environmentat/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:}' Service Code ..3 <br /> Assigned to Employee # Date / 7 <br /> Date Service Completed- - / / Further Action Required:• Y / . 'N PROGRAM ELEMENT <br /> Fee,Amount' ' Amount Paid.;; Date of Ps nt Payment T � Check #'' Recvd, B <br /> yme ymen ype: Receipt #, , y , - <br /> SUPV /_/ ACCT' _1 /�_ UNIT CLK /�� <br />