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C: <br />SERVICE REQUEST <br />L' <br />(SERVREQ)t7iSW/ ff <br />I 1 I <br />I <br />I�/ <br />RECORD ID #[� <br />�/� J/ BiLLINQW <br />Check # <br />FACILITY NAME <br />SITE ADDRESS <br />C I TY�Trl T� �o i �✓ CA Z I P <br />OWNER/OPERATOR <br />DBA <br />ADDRESS <br />CITY <br />APN # <br />STATE ZIP <br />NC # <br />y# 04- <br />BILLING <br />4 <br />BILLING PARTY Y / :—N:::] <br />PHONE #1 ( ) <br />PHONE #2 ( ) <br />Census --------- <br />BOS Dist Location Code City Code ------ <br />CONTRACTOR and/or <br />SERVICE REQUESTOR f �U ��/'t L t1 BILLING PARTY Fry <br />/ N <br />DBA <br />PHONE #1 (_)-- <br />MAILING <br />)- <br />MAILING ADDRESS 'NSC 1� 6 1-71 FAX # ( ) <br />CITY _SC 11 C -k �%a�! STATE C A— ZIP '1.5— .7 0 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all Ij 44, <br />, ro.ect specific <br />PHS/EHD hourly charges associated with this facility or activity will be billed to the party identiAi a YING PARTY on <br />Page 1 of this form. ivLen <br />DEC <br />I also certify that I have prepared this application and that the work to be performed will be Aw 1uwrrSY alt SAN <br />UNT <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. PUBLIC HEALTH S Cf2VIC ES <br />/ ENVIRONMENTAL HEALTH 01WISION <br />APPLICANT'S SIGNATURE : <br />Title: ) hCiv r ex— 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:/9�Ir �4-s�-1 Service Code <br />Assigned to Employee # Date <br />Date Service completed / / Further Action Required: Y / PROGRAM ELEMENT 3 e V <br />Fee Amount <br />Amount Paid <br />Date of Payment Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />un <br />)x <br />REHS / / SUPV _/ / ACCT _/ / UNIT CLK _/ <br />