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d <br /> SERVICE REQUEST0 VREG) Revt /93 <br /> s• <br /> FACILITY ID # RECORD ID # INVOICE <br /> FACILITY NAME Lh'�c�,��ilf�e! f�Lc'e�ie/"70e� BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY 2LI,f' Z[P <br /> OWNER/OPERATOR C L "� BILLING Y / N� <br /> DBA y f� PHONE #1 ( ) <br /> ADDRESS '/`TUU � 57E ✓�} PHONE #2 ( ) <br /> CITY STATE STATE ��7'� 21P <br /> t—nru !t Larxi Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> 3FRVICE REQUESTOR BILLING PARTY Y / N <br /> DBA PHONE 01 ( ) <br /> MAILING ADDRESS FAX # ( ) <br /> CITY 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 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, 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 /> Nature of Service Request: ---rAft(lc.. Fac. �� 1 Service Code <br /> Assigned to ` J /a lJC 1 { Employee # 0r `1 � Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RFHS _/ / SUPV _/ / ACCT �1��1 / UNIT CLK <br />