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0 SERVICE REQUEST to <br />ZSP? <br />(SERVREQ) Revised 8/23/43 <br />L <br />LLING PARTY Y / <br />DBA F ra 1Z Y I > ro o/d FYI a V' � PHONE #1 C3 Q )37- <br />G � <br />ADDRESS U / WV U %•l l /' L / L PHONE #2 ( ) <br />CITY < r� C C a STATE ZIP <br />= APN # Land Use Application #=IL <br />L90S Dist Location Code <br />iNTRACTOR and/or <br />RVICE REQUESTOR `( Q V r�1 V I l^l%/n P �ZL <br />ILLING PARTY Y' / N <br />DBA __ PHONE #1 O ) - <br />M Tun_ annoFcc 0"Y .tel Q /V— ( _ FAX # �)/y <br />CITY y�f 0 L /l STATE ZIP C� <br />TILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />)HS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />,age 1 of this form. <br />I also certify that I have prepared this application and that the .ark to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. <br />4PPLICANT'S SIGNA <br />91 / <br />Date: <br />u <br />WTHORIZATION TO RELEASE INFORMATION: In addition to the abovy, when applicable, I, the owner, operator or agent of same, Of <br />the property located at the above site address hereby authori:T: 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-epresentative. <br />Nature of Service Request:f/ <br />Assigner to Employe <br />e # _ Date rL / <br />Date Service Completed /_f Further Action Required: T / N PROGRAM ELEMENT Z ,� <br />REHS _/ / SUPV _J_J ACCT ?�/- I UNIT CLK <br />