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SERVICE REQUEST f (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # 5Y INVOICE # ba 3 S� <br /> FACILITY NAME C% t7'1tffj BILLING PARTY Y / <br /> SITE ADDRESS <br /> - �SOti� ` �✓t �s ��� <br /> CITY ti CA ZIP 3 <br /> OWNER/OPERATOR BILLING PARTY Y / N <br /> DBA PHONE #1 ( ) - <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR_ 4:-� o L�Aw v"� BILLING PARTY <br /> DBA lea PHONE #1 ( 20 ) 3i - L042 <br /> MAILING ADDRESS �1 Q-t � FAX # (20!1_)5;-CJ�SZ <br /> 1'BILCITY LAO _-imn STATE C,6 ZIP 41';9- <br /> BILLING <br /> LING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourty charges associated with this facility or activity will be bit-led 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 accordancePAMW 41- <br /> JOAQUIN COUNTY Ordinance Pes and Standards, State and Federal laws. R F r ll-�Pirr- <br /> + c-�L .wS h� OC 1 1 i 1995 <br /> APPLICANT'S SIGNATURE <br /> SAN JOAQUIN COUN;"Y <br /> Title Yf.-� SIT Date: �' ---PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when arpticabLe, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the rel ase 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. p(Q( <br /> Nature of Service Request: Service Code <br /> Assigned to �1,I}UIY _ Employee # IVA Date <br /> Date Service Completed l V _/ ^/ A Further Action Required: Y / !IN 1 PROGRAM ELEMENI,13�_!:Tt <br /> Fee Amount Amount Paid Date of Payment Payment ype Receipt # Check # Recvd By <br /> 00 <br /> RENS / SUPV _/ / ACCT 0 / /q� UNIT CLK / 1 <br />