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SERVICE REQUEST <br />0 SEN 00 61) Revised 8/23/93 <br />FACILITY ID # RECORD ID # INVOICE # <br />FACILITY NAME <br />SITE ADDRESS ntII <br />CITY Q CA ZIP 2 5-2— q " <br />F BILLING PARTY Y <br />OWNER/OPERATOR but f 9, f 87 ' ' BILLING PARTY Y / N� <br />DBA !\Z.�� M1�it 1. e �' I PHONE #1 (�)-OqZl <br />ADDRESS �D ! l ! �G # ?l man DI PHONE #2 ( <br />CITY L C1 I STATE ZIPy <br />FAPN # Land Use Application # <br />A� •z � (5 . � 11 BOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR�y " - FBILLING PARTY Y / N <br />DBA PHONE #1 <br />MAILING ADDRESS � 2-C) <br />�qtL-_ <br />CITY �-�� STATE C-R ZIPC)`CC <br />FAX # <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site andAWMENT ific <br />PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as tiI'1e%MtiY an <br />Page 1 of this form. <br />MAR 1'71998 <br />I also Certify that I have prepared this applicat on and that the work to be performed will be done in accordance with all SAN <br />jOAOUIN COU'RTY Ordinance Codes and tanvdard , e and ral laws. pSANJ0AC7IJINGr7i,�ky <br />ENVIRON I , TA LTH senvick's <br />MENTAL HE'gLTH DIVISION <br />APPLICANT'S SIGNATURE <br />3 <br />Title • � Date- <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when eppliSable, I, the owner, operator or agent of same, of <br />the property located at the above site address hergjy atithori;e the release of any and all results, geotechnical data and/or <br />environmental/site assessment information to SAN 4OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL WEALTH DIVISION as soon as <br />it is available and at the same time it is providad tp Mg or my representative. <br />Nature of Service•Request:ft&tt-arviw Code <br />Assigned to 1�L` /U( Employee 0 cl o Date /__/ <br />Date Service Completed // Further Action Required: Y / N PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Paymant Type <br />Receipt # <br />Check # <br />Recvd oy <br />SUPV_/ / ACCT _._J / UNIT CLK <br />