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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # l./ INVOICE # <br /> FACILITY NAME ` �/1 { ' ` !�V BILLING PARTY Y / N <br /> SITE ADDRESS <br />• CITY CA ZIP ��il'l <br /> M'kc.�l.a2( KC�✓'ve-W <br /> OWNER/OPERATOR V qL BILLING PARTY Y / N�J <br /> DBAj�� PHONE #1 <br /> ADDRESS — f PHONE #2 <br /> CITY STATE ZIP �lS <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR t'I� (� lJ�� Y �_V �lJ BILLING PARTY Y) / N <br /> DBA ( � vl "" PHONE #1 ( ) a- o- <br /> ry 14 -23 <br /> MAILING ADDRESS FAX <br /> CITY STATE _ ZIP �'f <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 /> 1 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 /> yWfVVIEH <br /> APPLICANT'S SIGNATURE <br /> NOV 19 1996 <br /> Title: Date: <br /> SAN JOAQUIN CVUNTI <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the ownepljfppgOLYALPrF ag \/OfEOme, of <br /> the property located at the above site address hereby authorize the release of any and al�N►$ 1 �E9�a.���hYaTFdhk�'ISrKd/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 i1y (� Wv Employee # l Date <br /> Date Service Completed / / Further Action Required: Y / NPROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> -A,0D <br /> U � <br /> SUPV ��1 / / ACCT / / UNIT CLK _/ / <br />