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SERVICE REQUEST <br />! F ix sf- <br />(EH 00 61) Revised 8/23/93 <br />[FACILITY ID # l�C l RECORD ID # INVOICE # <br />FACILITY NAME ��� BILLING PARTY Y / <br />SITE ADDRESS 14403 `' l� CwL c ct-is ® <br />CITY J (vG�T�/�' CA ZIP �I <br />OWNER/OPERATOR /� 1 vIrIC S� �' BILLING PARTY f / N <br />DBA OJ © PHONE #1 ( <br />ADDRESS Z�V Off"^ »+ L �`� iJ :9- �"' PHONE #2 ( <br />CITY -4'" 40 COa-Q(:` ^ STATE KA ZIP � Z <br />IAPN # Land Use Application # <br />2" -23- 2- - -4F BOS Dist Location Code <br />CONTRACTTORllaan�d/or —1 <br />SERVICE REQUESTOR =BILLING PARTY Y / �J <br />DBA PHONE #1 ( ) -- <br />MAILING ADDRESS FAX # ( ) - <br />CITY <br />STATE ZIP <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`EEE W- tified as the BILLING PARTY on <br />Page 1 of this form. 0I:d-CIItrrw <br />I also certify that I have prepared this application and that the work to be perfaPkdUd iil tJa7Ee in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Co a d Standards, to and Federal laws. SAN JOAUUIiv COUNTY <br />PUBLIC HEALTH SERVICES tL(J J <br />APPLICANT'S SIGNATURE E N VI <br />♦♦ ■ <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, <br />the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/ r <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br />it is available and at the same time it is provided to me or my representative. of l aA <br />Nature of Service Request: <br />Assigned to 'PQ -u. .), L Employee # <br />Date Service Completed / / Further Action Required: Y / N <br />Service Code <br />Date�/� I�/ <br />PROGRAM ELEMENT !- V'D <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />RENS <br />_/ / <br />SUPV <br />&—/ / <br />ACCT �/ �� / _ <br />UNIT CLK <br />_/ / <br />M <br />RENS <br />_/ / <br />SUPV <br />&—/ / <br />ACCT �/ �� / _ <br />UNIT CLK <br />_/ / <br />