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2 1996, <br /> SERVICE REQUEST CEN 00 61) Revised 8/23/93 <br /> FACILITY ID # �U �C RECORD ID # D/// - INVOICE # <br /> FACILITY NAME ,��AkA ! BILLING PARTY <br /> SITE ADDRESS x'15\ <br /> CITY 11LO3\ \CA zip �152yz <br /> OWNER/OPERATOR 'GS�IA' BILLING PARTY Y / NO <br /> DBAty�\�I \ / PHONE #1 ( oZ )��.- Z855 <br /> ADDRESS a�/`a� II oA\ l -wVy-*N PHONE #2 QQ00L ) ;bk - )y <br /> 1^ <br /> CITY 1 Fto�J(VI STATE AZ, ZIP $SMLL <br /> �APH # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or � \ <br /> SERVICE REQUESTOR ,W A4J.IC - n Z NI BILLING PARTY <br /> DBA WPYA11\��N``� `n PHONE #1 ( ��4_) FtZlo ' DZZ <br /> MAILING ADDRESS FAX <br /> ,r r� (7fy � 5ZJ <br /> fJ - 7$ O <br /> CITY l X)LNQ Pra- STATE�_ ZIP -I WDZI <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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 StADdards State and Federal laws. - <br /> APPLICANT'S SIGNATURE I�• lJ n�� W �fQ.0.-I I <br /> Title: V IC.L TQ.ASr&—k- Date: � Z/ZA <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 /> envirormenta L/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: e11A 01je i ,.( Service Code <br /> Assigned to �ViL y— U-f v--o— Employee # n(OCO Date �J <br /> Date Service Completed a/ / Further Action Required: Y / N PROGRAM ELEMENT 2-- Z�/ <br /> Fee Amount Amount PaidDate of Payment Payment Type Receipt # Check # Recvd /Bpy� <br /> /--/9 /'.G UNtT CLK / / <br />