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SERVICE REQUE[S�T (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # IRECORD ID # 7(G 7 INVOICE <br /> FACILITY NAME BILLING PARTY <br /> SITE ADDRESS 2470'1 /CNAMf y 000, <br /> CITY 'o CGE..d-s1, CA ZIP <br /> OWNER/OPERATOR (f3s l�� Pe e Y BILLING PARTY 02�.^ , �,I/ N <br /> DBA _ � eg PHONE #1 (�) 'OmaOv - 11 V7 <br /> ADDRESS '30PHONE #2 ( ) <br /> CITY , r"e` &,4A0 STATE tA ZIP 1571771 <br /> APN # Fd Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR JCM ICJ rL BILLING PARTY Y / !� <br /> DBA aUI�• ('J PHONE #1 ( 20 _) SZY - 96�a <br /> MAILING ADDRESS 17,1 1th .�1 / C_ FAX # ( �1 )SZ'y - bSV3 <br /> CITY M�^1�5�0 STATE CA ZIP , 3Sl PAYMENT <br /> r-(„Z <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all a /o ct 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 /> SAN JOAQUIN COUNTY <br /> Page 1 of this form. PUBLIC HEALTH SERVICES <br /> ENVIRONNN*NTAL HEALTH DIVISION <br /> 1 also certify that 1 have pre ed this application and that the work to be performed will be done ,it . <br /> JOAQUIN COUNTY Ordinance Code end Standards, State and Federal taus. ' '( <br /> L�/ <br /> APPLICANT'S SIGNATURE II�� <br /> Title: AteuA+ 1"r "�i1�1f Date: <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 Sery"yi/ceet Request: - ) p Service Code <br /> rC () � <br /> Assigned to 1 /\1� ` ` Employee # V T I CI Date 0 <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS CD-/—L _/ • SUPV ��/_/_ ACCT <br />