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"RECORD <br />ERVICE REQUEST (EN 00 61) Revised 8/23/93 <br />FACILITY ID # INVOICE # <br />FACILITY NAME BILLING PART Y / N <br />SITE ADDRESS <br />CITY CA ZIP <br />OWNER/OPERATOR BILLING PART Y / N . <br />DBA PHONE #1 ( ) <br />ADDRESS PHONE #2 ( ) <br />CITY STATE ZIP <br />APN # Land Use Application # IF <br />BOS Dist location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR BILLING PARTY Y / N <br />DBA PHONE #1 ( ) <br />MAILING ADDRESS <br />CITY <br />STATE ZIP <br />FAX # ( ) <br />4 <br />BILLING ACKNOWLEDGEMENT. 1, 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 bitted 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 />I APPLICANT'S SIGNATURE : <br />Title: <br />Date: <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 sane time it is provided to me or my representative. <br />Nature of Service Request: I Service Code <br />Assigned to 1 Employee # <br />Date Service Completed _1 / Further Action Required: Y / N <br />Date <br />PROGRAM ELEMENT <br />RENS / / - SUPV _/_/ ACCT I _/ / UNIT CLK' <br />c 1 <br />