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ev� SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> [rAC`iL�1TYID # Q INVOICE # <br /> FACILITY NAME V IlJ G G� / OILLINQ PARTY Y / <br /> SITE ADDRESS <br /> CITY Y����L--"4 CA ZIP <br /> OWNFR/OPERATOR V �U d — -- FRILLING PARTY Y / /4" <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> ---APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or r <br /> 1/J%� �� (, '� BILLING PARTY C / N <br /> SFRVICE REQUESTOR // r <br /> DBA <br /> PHONE #1 ( ` ) �c'e- - �Y F, <br /> MAILING ADDRESS �aeL � 4 FAX # (,20 <br /> CITY U✓LJo C_.�C STATE ZIP J 3 C'f <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/END hourly charges associated with this facility or activity will be bitted to tPA"i eN Tfed as the BILLING PARTY on <br /> Page 1 of this form. RECEIVED <br /> I nlso certify that 1 have prepared this application and that the work to be perforKA1111 a a4in accordance with ell SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. SAN JOAQUIN COUNTY <br /> Q PUBLIC HEALTH SERVICES <br /> APPLICANT'S SIGNATURE : � �-` �` /� ENVIRONMENTAL HEALTH DIVISION <br /> Title: Date: �� r <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of aame, of <br /> the property located at the above site address hereby authorize the release of any and ell results, geotechnical date 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 R eat: Service Code <br /> Assigned to {` Employee # ) Date / , <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT -Z 3 ) 6 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> s��' <br /> RENS- SIJPVAmdilkLACCT /L9 CI Y UNIT CLK / 1 <br /> -— <br />