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• SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> [FACILITY ID # RECORD ID # <br /> INVOICE # ? �9�t f <br /> FACILITY NAME (2C� 'Lt F-�'� �^ BILLING PARTY Y / 1\N <br /> y <br /> SITE ADDRESS �-7 '?C) <br /> CITY J V �1L �^ ``' CA ZIP I <br /> OWNER/OPERATOR may`" "� BILLING PARTY Y <br /> DBA / PHONE #1 <br /> ADDRESS �0-- C� (��L" -� PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # Land Use Application #IF <br /> I- BOS Dist Location.,Code <br /> CONTRACTOR and/or �) <br /> SERVICE REQUESTOR BILLING PARTY �Y' / N <br /> DBA PHONE #1 <br /> MAILING ADDRESS �' ''-[ `� —�� �_ FAX # ( ) <br /> CITY �� i 7— STATE �' ' ZIP ( 32— <br /> V <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 /> I also certify that 1 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 �tAndards, State and Feral laws. <br /> 815:���- <br /> APPLICANT'S SIGNATURE <br /> HEALTH SFi`' 6t: <br /> THTitle: �LDate HEAL : <br /> DIVISION <br /> i <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 /> 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 ttoo�mee o(r� my (representative. <br /> `(1JC�-�X�c <br /> Nature of Service Request: Service Code �---- <br /> r <br /> Assigned to 0 Employee # V `p 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 /> SUPV _/ / ACCT _/ / UNIT CLK _/ / <br />