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0 0 <br />SERVICE REQUEST <br />(EH 00 61) Revised 8/23/93 <br />CITY f�/ CA ZIP <br />30�6 <br />OWNER/OPERATOR <br />DBA <br />BILLING PARTY Y / N <br />PHONE #1 ( <br />ADDRESS PHONE #2 ( ) <br />CITY <br />Amount Paid <br />STATE <br />ZIP <br />APN # <br />C # <br />Land Use Application # <br />Fee Amount <br />--r <br />2 3�•, oa <br />rj22 <br />BOS Dist <br />Location Code <br />-- — <br />BILLING PARTY Y / N <br />CONTRACTOR and/or <br />/� <br />&�67 <br />REQUESTOR <br />CSERVICE <br />PHONE #1 (qfL)M'4_ <br />DBA <br />� <br />FAX # ( & '� <br />MAILING ADDRESS <br />✓CJ C) o <br />Y ///�/�! <br />CITY lJ STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, 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 />Page 1 of this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in EmoffmNlh <br />all SAN <br />JOAQUIN COUNTY Ordinance Codes and/tandards„ State a ederal laws. RECEIVE <br />n O� �l <br />APPLICANT'S SIGNATURE <br />/p /J//J Date: / �/ -� <br />T i t l e: (/ //" AF1JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, o h@W W-W�eWb1f+ lodf <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 />Nature of Service Request: Service Code O — <br />Assigned to ,L � 6 4,a zt+ Employee # rlt� i --`5 <br />Date Service Completed / _/ Further Action Required: Y / N <br />Date <br />PROGRAM ELEMENT 2'.AO(,o <br />RENS _/ / SUPV ACCT I. �/ a 3 / UNIT CLK <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />C # <br />Recvd By <br />Fee Amount <br />231- 00 <br />2 3�•, oa <br />9 <br />9 ZI .7 <br />rj22 <br />RENS _/ / SUPV ACCT I. �/ a 3 / UNIT CLK <br />