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a_ <br /> SERVICE REQUEST . „Q�iVE 8/23/ <br /> [FACILITY ID # RECORD ID # q, INVOICE # 7 <br /> FACILITY NAME g1LLING PARTY Y / N y <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATOR <br /> DBA PHONE 01 (S0 ) <br /> ADDRESS 76 UV &i PU 11 63PHONE #2 (J/(] ) VP3- <br /> CITY �C ILU I O{��/ STATE ZIP <br /> FAPN # Land Use Application # <br /> SOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR L/LC ( Qir��ll Z� C BILLING PARTY Y / <br /> DBA �'L `-/ PHONE #1 ( ) - 4AIN D <br /> MAILING ADDRESS -( `n S71- FAX # <br /> lfZBICITY SC-tkA JOS-f- STATE cn ZIP 5112— <br /> BILLING <br /> LLING 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 /> I also 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 and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title° Date: <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 /> envirormentaL/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 Reque�s�t/:,,�'a ��1!✓�< r�19 UQL Service Code <br /> Assigned to ((,v M 6_ Employee # 6/1Z Date ___J_/ <br /> Date Service Completed / / Further Action Required: Y ! N PROGRAM ELEMENT AP3rO <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS _/ / SUPV _/_f ACCT _�_� UNIT CLK _f / <br />