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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # y INVOICE # <br /> FACILITY NAME %k AN "G 9 r Cj. BILLING PARTY Y / N <br /> SITE ADDRESS ���C� F(�.S fro A'vE ' <br /> CITY ' l �G � CA ZIP rff <br /> OWNER/OPERATOR WIi�FZi= R�1J U� c> BILLING PARTY / N <br /> DBA V F' i/�A�l '�4-ems PHONE #1 5zZ 04$2 <br /> ADDRESS <br /> P•O. �x ?j 01-> PHONE #2 (2�)�3 I 4-:34 — <br /> Z <br /> CITYSToGK-��1-4 STATE GA ZIP 3 <br /> APN # IF Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or I� , <br /> SERVICE REQUESTOR V R Rte ' �'�~Y k�d N So N BILLING PARTY Y / <br /> DBA PHONE #1 (91 6 ) - +7 <br /> MAILING ADDRESS I Z-17 FAX # ( ) <br /> CITY 1-t4C>tb7 C.0 �d�y�a STATE CA ZIP <br /> B:I.LING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/FHD 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 /> 1 also certify that I have prepared is application and that the work to be performed will■be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance C es a S a ards, State and Federal laws. ORr <br /> APPLICANT'S SIGNATURE Y <br /> �-2,f'-cid F EB 2 5 199 ' <br /> Title:- U� Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, op6ialtor or agent ofEtame, of <br /> ,, <br /> the property located at the above site address hereby authorize the release of any and al��'+4it ts, geotechnicat!de Cbovvdr <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: �� /�,tMNv"r � It rx� Service Code l <br /> \� ��- <br /> Assigned to � -� K. �"�" Employee # C? Date / ° <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 7, w` <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> FHS l- /d-'S `I SUPV _/ / ACCT UNIT CLK I —/ /-- <br />