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SERVICE REQUEST <br />(EH 00 61) Revised 8/23/93 <br />FACILITY ID # RECORD ID # I i ��c) 1 INVOICE # D 34 L-1 <br />FACILITY NAME / i-t�, L5 01, i1 A/ZI'17 r �• >( BILLING PARTY Y <br />SITE ADDRESS <br />CITY 7 -Cr CA ZIP <br />OWNER/OPERATOR / 7 kC7CI 1'o7Q BILLING PARTY / <br />DBA / ! " 7 ("lam r' . fP /i. �' / PHONE #1 <br />ADDRESS �°7 �^ L �• TC PHONE #2 ()- <br />CITY<CL STATE _ ZIP <br />APN # Land Use Application # - I--- <br />BOS Dist Location Code <br />CONTRACTOR and/or lA/C / <br />SERVICE REQUESTOR �In Citi / � -17 7 G n G BILLING PARTY <br />DBA "6K PHONE #1 (-LLL-) <br />MAILING ADDRESS,^ <br />FAX # C2 -0S ) N (-k- <br />CITY k - <br />CITY — Lo /T STATE (f ZIP S 'J <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 />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, Stay and Federal laws. <br />APPLICANT'S SIGNATURE <br />TitLe: <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: / F --I- �G L .i) " a � /USLA�' �5'ervice Code � U� <br />Assigned to�- Q-/ Employee # Date <br />l <br />Date Service C (Ited / Further Action Required: Y / N� PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />_/ / <br />NS <br />F <br />_/ / <br />SUPV <br />_/ / <br />ACCT�0�/ <br />3I / �� (-( <br />UNIT CLK <br />_/ / <br />