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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # �j Cl�C�� RECORD ID # Q .1, �j 171 INVOICE # <br /> FACILITY NAME 1�1 R�l� fG Fc,C1 I I i� LI L� V J BILLING PARTY Y / N• <br /> SITE ADDRESS 005 N Cen`te.T Jk . —i I <br /> CITY <br /> tF�J�C)C)aQY� ` CA ZIP g57,0a <br /> OWNER/OPERATOR Ni LO RocAVLI1,S CO ' BILLING PARTY Y / O <br /> DBA (R 1/T 1`1 N', E \A A 5 PHONE #T (1� > to l(� - `:)`1 14 <br /> ADDRESS {�P_ll) . C)'A L n(�O �T PHONE #2 ( ) <br /> CITY 1\C ICSIG., STATE ZIP <br /> p APN # Land Use Application # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or `` Q -_[()C ;� <br /> SERVICE REQUESTOR w f non TC �O(5 _LC � BILLING PyA{R�T/Y� C' � / N <br /> DBA PHONE #t ��-J bpi 1— <br /> MAILING ADDRESS �5�Cli W 1 IL�QM � f \ FAX # <br /> C ( ) <br /> CITY )�oc-_i�� �(lYl STATEZIP plc 11`o C) <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page I 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 end Standards, State and Federal laws. J A N 1 4 .iJ! <br /> APPLICANT'S SIGNATURE —'4 <br /> rLAKIC HEALTH SERVICES <br /> Title: .� Date• �.�. " c�. y, "LL- _P41RONI.:1EhTAL HFAI_-P ')tVISJ&, <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 same time it is provided to me or my representative. ' ^ <br /> Nature of Service Request: ��,,// Service Code <br /> Assigned to � � dlw Employee # Date 22y 7 <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 7-3 <br /> 63 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> day' �23 V (- <br /> RENS /�/_� SUPV / /_ ACCT _/ / _ UNIi CLK _/ /_ <br />