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FACILITY 1D # <br />IAr.tI_ITY NAME <br />SITE ADDRESS <br />SERVICE REQUEST <br />(SERVREO) Revised 8/23/93 <br />I 1 Q 1� 0 I RECORD ID # I I INVOICE # <br />Cr r__E/ Q I7/-1, CA ZIP / z <br />nw?lrR/Or ERA TOR ���W d r'f6jh, J I BILLING PARTY Y / N <br />1) RA PHONE #1 ( ) <br />ADDRESS ' /� V t �c��' I� I C� /`''/ PHONE #2elf <br />( ) <br />CITY/L�wV �CL� STATE ZIPG <br />rArNF Land Use Application # �j <br />BOS Dist Location Code Ll <br />r,nHTPACTOR and/or / rf) <br />1�rPVIrF RFOUESTOR Wil) BILLING PARTY Y // /N! <br />DRA l/ ,/% C L� 7J f'i l/�if�`�"'J PHONE #1 <br />MA I I INC ADDRESS FAX # ()z 2 Z <br />CITY ��X (�T� �f� STATE "T - ZIP �2 <br />RII.LING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />rnge 1 of this form. <br />I nlsn 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 nd Standards, State alnddeederat laws. <br />ArrLICANT S SIGNATURE � <br />Title: l �`�IU��D �i— f��'W �^/ Date: <br />2-2, <br />AUTHORIZATION <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br />the property located at the above site address hereby authorize 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 representative. <br />Nnture of Service Re/q/uest:/ Service Code <br />Aasigned to // J Q.ye Employee # / 7 ( Date <br />Date Service Completed -/-/ Further Action Required: Y / N PROGRAM ELEMENT) �- <br />Fee Amount <br />Amount Paid Date of Payment <br />Payment Type <br />Receipt # <br />Check# <br />Recvd By <br />PFHS / _/SUPV _/_ _/_ ACCT n /'! / UNIT CLK <br />