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SERVICE REQUEST PAVMEN(1v,sed 8/23/93 <br /> FACILITY ID # RECORD ID # )V!� INVOICE #n� CI <br /> (� lll,,, yr SAN t- •`. <br /> KI ;-baU P�flaF�'YT'TPF'T�' ikQ� -- I AL HSE: VIC N <br /> FACILITY NAME n CJ 1 �����AA - E M AL EAITH 1 <br /> SITE ADDRESS i ms 01n F'4'1 A t r prcl l.CA1 ^ n <br /> CITY _� -rr—)<"�E'tnn CA ZIP95,Qccp- s_11_A <br /> , <br /> OWNER/OPERATOR S+.a+e r7 I'.Oy,.�{Jr(ll0` BI LLINGpPARTY ^�Y G/ �N—I <br /> DBA �^ �_L PHONE 91 (-1 -7 1�1� <br /> ADDRESS 131)n I J1',�ree (�]CPPHHHONEI '#2 ( ) <br /> CITY S C-C"rrfNeI�ZU STATE` ZIP `"I JC714 <br /> APN # Land Use Application # SOS Dist Location Code - <br /> CONTRACTOR and/or '::;g <br /> SERVICE REQUESTOR ` -LAX � BILLING PARTY p�ypY / N <br /> DBA /� �j PHONE #1 (gL)0Q,9 - ,-O <br /> MAILING ADDRESS P.0., Box -7-7FS� /'+ ,, FAX # (9E0 )" - ��� <br /> CITY V/ 14 c0 STATE CT ZIP 959 a-� <br /> BILLING ACKNOWLEDGEMENT: I, 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 /> I also certify that I have prepared this appLic ion and hat the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Stand ds4 <br /> , a and ederal Laws. <br /> APPLICANT'S SIGNATURE : 1 ��yy <br /> Title: CL- Date: -e)-qc0 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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: L? <br /> Assigned <br /> Code 3 <br /> Assigned to Employee # J 1 3 Date Lt-_/ <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 /> RENS —/_ SUPV _/_/_ ACCT —/_/ -�c_- UNIT CLK _/_/_ <br />