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SERVICE REQUEST to (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # / `� INVOICE # <br /> FACILITY NAME QTY ( � BILLING PARTY Y / <br /> SITE ADDRESS 93 0 <br /> CITY &gL CA ZIP gsa91`0 <br /> ER/OPERATOR cz� w i/1 BILLING PARTY Y / <br /> rp <br /> DBA PHONE #1 Q 369 - 3 7S.5-- <br /> ADDRESS _j4J644C4 0-0 ay-r*-trf PHONE #2 <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> F BOS Dist Location Code <br /> CONTRACTOR and/or ,,¢— <br /> ERVICE REQUESTOR t I V V aW�/��e_�_'�.� BILLING PARTY (!f)/ N . . <br /> DBA 1, « I I �� PHONE #1 (26 ) 1/6 <br /> ILING ADDRESS�`S�.S ___ FAX # (.20 > 4/(, - 6 <br /> CITY STATE _ ZIP l 5S� <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 /> ' YC ENT <br /> 'I also certify that I have prepared this application and that the work to be performed will be done in accor +�Ity1! SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federijl laws. <br /> �PPLICANTIS SIGNATURE 2 01998 <br /> (� /� SAN JOAQUINHEALTH <br /> SERVICES <br /> Title: T' � Date:—�/ /- PUBLIC HEALTH SidRVICES - <br /> NNIENTAL HEALTH DIVISION <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 (rtime it is provided to me or my representative. <br /> Nature of Service Request: v\ Service Code <br /> Assigned to mployee # "1 Date --- <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 3 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 7- J114 , _. t t'1 <br /> LE <br /> FECA SUPV _/_/ ACCT _/ / UNIT CLK _/_� <br />