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0 SERVICE REQUEST (SERVREQ) evised 8/23/93 <br /> on Jul <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME #ILLING PARTY r N <br /> SITE ADDRESS J N <br /> CI - ✓lJ - CA ZIP <br /> -5. <br /> OWN /OOR BILLING PARTY Y / N <br /> DBA r\ PHONE 01 ( � <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> ArN # .-. — Land use Application # <br /> E <br /> Dist Location Code <br /> =r-0NTRA1C:T0R:),d/or <br /> SERVICE REQUESTO9:-5-VT-'n-'�-'T1M14.- IC,=, •-r "l Tt- BILLING PARTY Y / N <br /> DBA PHONE #1 ( g�y) -e= <br /> MAILING ADDRESS �Dr � o e_ FAX # (=� lIr <br /> CIT . STATE', _ ZIP�J <br /> BILLING 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 /> Page 1 of this form. <br /> 5:y/ s <br /> I also certify that INTv�ere r this application and that the work to be performed wilF e� eordt h all SAN <br /> JOAQUIN COUNTY Ordinas and t~ rds, Steffe aid Federal laws. �Niyj /7E;�S `%v `t <br /> APPLICANT'S SIGNATURE I T <br /> Title, Date: <br /> 2 � /S/% <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 /> Nature of Service Request: /! Service Code -`� <br /> Assigned to I l�da e Employee # l ) Date <br /> Date Service Completed / / Further Action Required: r / N PROGRAM ELEMENT 3V o-r> <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RE"S _/ __/__ SUPV �/ / ACCT _f�� _ UNIT CLK <br />