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oLc��J OA <br /> SERVICE REQUEST ` (SERVREQ) Revised 55//13/93 <br /> FACILITY ID # RECORD. ID # BILLING PARTY Y <br /> FACILITY NAME - L . C•R.T <br /> SITE ADDRESS 3y �' w 51' e- V <br /> CITY N CA ZIP 6 <br /> OWNER/OPERATOR PO A—T- 07 S�l� BILLING PARTY Y / NO <br /> DRA C'fI RC9/ �-L /LE/F� PHONE #1 < ) <br /> ADDRESS PHONE #2 ( ) <br /> (CITY STATE ZIP <br /> APR # /� r �9 Census ---""--- BOS Dist Location Code City Code ------ <br /> / CONTRACTOR and/or <br /> V SERVICE REQUESTOR BELLING PARTY 0= <br /> N <br /> DBA ONE #1 ( ) <br /> MAILING ADDRESS v FAX # ( ) <br /> CITY 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 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 /> v APPLICANTS SIGNATURE : <br /> V/ Title: Date: <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 to me or my representative. 7. <br /> Nature of Service Request: rx /C P!J � � Service Code <br /> Assigned to Employee # D Date <br /> Date Service Completed / / Further Action Required: YO / N PROGRAM ELEMENT Z- /• 6C> <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 00 <br /> REHS / / SUPV _/ / ACCT _/ / UNIT CLK _/ / <br />