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/ VI IM!/ .!•C,rJr1I1 rRVI`"1 r <br />SERVICE REOUEST LEN OD 61) Revised SM/93 <br />FACILITT 10 I ' O I f� RECORD 10 M UN) iii � � I INVOICE <br />FACILITY NAME <br />1\ I lfk►fA I ,�fAAid t/ . ,V 41 BILLING PARTY U / N <br />SITE ADONESS o 4 N 1 `i Q <br />CITY nu <br />1 ztv Cl 3 <br />WIEN/OPERATOR J Mac GILLING PARTY c Y / N <br />DNA PHONE I/ <br />ADDRESS <br />r -ITT <br />/ <br />CONTRACTOR IwWor ���� <br />SERVICE REOUESTOR <br />DNA <br />STATE <br />Land Use Application 4 > <br />ZIP <br />P,lm rz Lei )sgr _ INTI <br />NDS Dist i ilocat ion Code <br />NI LLING PARTY <br />+, FAX 9 <br />Nul:xa wn>aEss Ai2i�t'ry1 S � � Pi S�. <br />CITY /tet✓''t� J�G STATE ( /I- <br />ZIP <br />BILLING ACKNOWLEDGEMENT! 1, the Undersigned owner, operator or agent of salla, acknowledge that art site andlor project specific <br />DNS/END hourly charges Associated with this facility or activity will be billed to the pwty identified as the BILLING PARTY on <br />Page 1 of this form. <br />1 stso Certify that I have prepared this application and that the work to be porforssed wilt be done In actordance with all SAN <br />JDADUIN COINT1 Ordtnanoe�odg; {anId SVWW* 'ds, State end Federal taws. ' <br />AppLICANf/S SIGNATURE <br />Title: <br />OL w ,eA <br />Date: (0-1b - <br />AUTHORIZATION 10 RELEASE INFO NIATION: In addition to the above, When applicable, 1, the owner, operator or agent Of some, of <br />theproperty Located at the above site address hereby authorize the retease of any and all results, geotechnical data and/or <br />ea/irm Atal/site staeasrrent info,notion to SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />.1._ •r. tip.. tt is eu nvided to ap or My repr"entattve. <br />.I .• ---- _. _ <br />�Y'�Y. - <br />Natvro of Service Regxst:, <br />Assigned to . _Lal, . f 4O-. l^ ( `7 r/.5 EaotOM K C> D D Date _�_ I ( d <br />f e <br />Date Service COnpleted _/,__/ further ACtiO Rmpfredt / N PROGRAM ELEMENT <br />Fee An t Aa t Paid Date of Payment Paysent Type Receipt I Check 0 Reevd By <br />