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SERVICE REQUEST (ER <br /> 44 (ER 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID 1#y Jlo,[ Sv INVOICE # - - <br /> FACILITY NAME Girde, k �9GIli+ly K 3011 Z015 BILLING PARTY Y / <br /> SITE ADDRESS 1(e4J.1-70 6.2mbrik?, Or. <br /> CITY t-8{•�1r�'P CA ZIP <br /> OWNER/OPERATOR '(D5G0 Marketlrtq CD • BILLING PARTY Y / N <br /> DBA 6 ircl e K PHONE #1 ( of > 5y8 - 7G12 <br /> ADDRESS 7& ►3roadWay AVG • PHONE #2 (q i(o ) ,5-56 <br /> CITY Gj9Grdwwh�D STATE 6 ZIPq�JSiB <br /> F <br /> APN # �FLand Use Application # <br /> IBOS Dts[ Location Code <br /> CONTRACTOR and/or / Ay /' -t- <br /> SERVICE REQUESTOR �a�Gar�&*onlno/- , Ager1T 4if `osro __ BILLING PARTY Y / // N <br /> DBA y(Z�Nt L i/c•A/tO�N Vrogf! 2 l nG• PHONE #1 ( `�) <br /> MAILING ADDRESS I l-10 WAILo, PQS5 94 . lwile, //�� FAX # ( _/I� ) (JOq <br /> CITY lDnwrd STATE CA ZIP '14lG/W , <br /> I <br /> �®."�'P gg f�i <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all s e ro)eecspec I <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. p/Lyp�� <br /> 1 also certify that I have prepared this application and that the work to be performed will be difnP�mW� nce with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal taws. RECEIVE® <br /> JIIN <br /> APPLICANT'S SIGNATURE : /rdw`w� <br /> Title:—Agsnl' Fw ToSGo Mk+ci , Go. Date: (0�7�yZia Re , neeNv-couNTY <br /> T PUBLIC HEALTH SERVICES <br /> ENVIRONMENTA <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, ope AityFA&THdOMOM 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: Service Code V <br /> Assigned to Employee # g � Date Ste/�- / <br /> Date Service Completed _/ / further Action Required: Y / N PROGRAM ELEMENT 'J C 3 <br /> Fee Amount Amount Peid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 5 ¢(v58.Sv l�1�3�g ✓ i i s 1 C,6 . <br /> ACCs <br />