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0 SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br />FACILITY ID # I I RECORD ID # 1:1- - to I 1 , / I INVOICE # I —/ v v <br />FACILITY NAME J�CJlfGZE---� BILLING PARTY Y / <br />SITE ADDRESS <br />CITY -�trjc_(�'4Ov� CA ZIP <br />OWNER/OPERATOR BILLING PARTY Y / N <br />rr��nr�da ri�i� <br />DBA t. PHONE #1 ( ) - cWc& <br />ADDRESS l ' f �l LSJ l % PHONE #2 ( ) <br />CITY TQX_ STATE _ ZIP <br />APN # Land Use Application # <br />F — ^^— =BOSDi--t <br />Location Code <br />CONTRACTOR and/or —^ <br />SFRVICE REQUESTOR BSc �-1 y�t,�Y�pl/` _ Cav�3�rt,�c.�/6 t, <br />DBA <br />MAILING ADDRESS (6q6 itJ�J&J&� G_yt <br />BILLING PARTY Y / <br />PHONE #1 ( ) SO- YS CC7 <br />FAX # (-)3(,7 S <br />CITY Q>d( STATE C "'-1 ZIP A5> -ZY6 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PNS/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 />1 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 Standar State and Federal laws. <br />APPLICANT'S SIGNATURE : <br />SAY � 1 ►��., <br />Title: Date- <br />JOAQUIN COUNTY <br />pUBL IC HEALTH ,ERVICE 10 �� <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, i, the owner, °°PN�r L r IRt I EAW* Ibws° <br />the property located at the above site address hereby authorize the release of an and all result`§NvgKotE <br />p p y y geotechnical data and/or <br />envirormental/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: II^^ Service Code <br />Assigned to � � _ Employee # V (� e Date <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # Recvd By <br />S <br />FREHS] <br />/ / <br />SUPV <br />/ / <br />ACCT <br />W Mr <br />S <br />FREHS] <br />/ / <br />SUPV <br />/ / <br />ACCT <br />/ / <br />UNIT CLK / / - <br />W Mr <br />