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1 <br /> `�✓ SERVICE REQUEST Mvg&O) Revised 5/iTM-" <br /> FACILITY ID # RECORD ID # BILLI1tG PARTY Y N <br /> FACILITY NAME �_1��,LQ <br /> SITE ADDRESS I e!j; <br /> CITY CA ZIP_q,52Z <br /> OWN(/0 ERATOR c r D BILLING PARTY <br /> DBA PHONE #1 <br /> ADDRESS W05-- "-' Z AAAE- PHONE #2 ( ) <br /> CITY �77O— l6 f STATE ZIP <br /> APN # Census --------- BOS Dist Location Code City Code ------ <br /> CONTRACTOR and/or <br /> SERVICE REQUESTORG OC- �j� ��_ �jl �-r74—VTOL �•l �-t�JR-1d c, BILLING PARTY F Y / N <br /> DBA PHONE <br /> MAILING ADDRESSFAX # (7-0 T)4 -� <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/END 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 /> APPLICANT'S SIGNATURE 4 <br /> 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. <br /> Nature of Service Request: Service Code J <br /> Assignedto� �t�s� Employee # US' Date _/ / <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT o F3 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> CZ--g)4, 07D 3�0� <br /> REHS _/ / SUPV _/ / ACCT / �� / ` UNIT CLK / / <br />