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• SERVICE REQUEST (SERVREQ) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME A e,,c L4 Y mo YA ea 1LLTN0 PARTY Y / N <br /> SITE ADDRESS <br /> CITY �/� I L44 ZIP <br /> OWNFR/OPERATOR L L /J BILLING PARTY Y // N <br /> DBA U� moi^ In�. S17f�L�. PHONE #1 ( !y ) - <br /> ADDRESS P o- 6)ax � L-� 45�00 PHONE #2CITY �( (fid STATE ` ZIP <br /> -APN # —Land Use Application # <br /> DOS Dist Location Code <br /> CONTRACTOR and/or <br /> SFRVIP_F REOUESTOR BILLING PARTY Y / N <br /> DBA PHONE #t ( ) <br /> MAILING ADDRESS FAX # ( ) <br /> CITY STATE ZIP <br /> RII.LING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PIIS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> rage T of this form. <br /> I nlso certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes end Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title- Date: <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 /> envirormentat/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 Request: C'�L J��e Service Codey <br /> Assigned to Employee # �'i �"/ Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT t �% <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> -- -- ,9 <br /> RFNS i_/ / SUPV _/__/ ACC �/ / UNIT CLK —/ / <br />