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SERVICE REQUEST <br />M (1 S <br />(EN 00 61) Revised 0/23/93 <br />iACIl17T IDN RECORD IDM © O =INVOICE <br />B'. <br />jpCIIITT NAME BILLING <br />PARTY <br />;. <br />stYE ABBREss C� �"�,� <br />CITY Ot`""` t�D' ` CA ZIP I� �"� ABF <br />OWNER/OPERATOR /(UJ�L{�1 , " 'RILUNO PARTY [L� J / N <br />DBA _ /QIt'L L� "— —'" • "" '� PHONE M1 (xrl) <br />�.bADDRESS PHONE 02 ( ) <br />CITYSTATE_ ZIP J <br />APN N Lard Uea Appl lest ion N <br />�153 ` 1 8v , BOS Diet Location code <br />'C(INTRACYOR mid/or smZ © 1 1 <br />SERVICE REOUESTOR J---1 L� j ��Q.� p �-rT BILLING PARTY Y ^/-1�r7 <br />�, DBA Int+✓ I W� T��' ` ' `-^ ` " t PO ^� PHONE N) (�)_- A <br />Zqj- <br />I ,WAILING ADDRESS I )Vim;)` /�� CIA\ FAI(N (—��I ) <br />CITY 6 ALE STATE r ZIP <br />I <br />BILLING ACKNOIILEOGEMENtt 1, the undersigned owner, operator or agent of Some, Dick It site and/or protect specific <br />I PNS/EIID hourly chargee associated with this facility or activity will be billed to (t.�la�lX\ +titled as the BILLING PARj1Lon <br />P4 Ni <br />' Page 1 of this form. <br />J c�atI <br />i I also certify that I have prepared this application and that the work to be perfo w �b19 o o in accordnrr2eCFnith o11,(A(t� <br />1 JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal lows. /t J,(JAJ-AIIN^r.IN" <br />r <br />Dates "/ _"9�A <br />AUTHORIZATION YO RELEASE INrORHAt IONS In addition to the above, when applicable, I, the owner, operator or agent of Sime, of <br />the property located at the above site address hereby Duthorl[e the release of any and all results, geotechnical date end/or <br />bnvironmental/site Aeaesseent information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon an <br />,♦ ,- _ _..u..1 ,...e nr w renresentativa. <br />Service Code <br />Nature of Service <br />rRequests <br />l <br />Aeelgrled to Enployes N <br />Date <br />Further Action Nequlred: Y <br />d N PROGRAM ELEMENT l- <br />Date Service Coapleted _/ / <br />y <br />Fee Amourit Assount Paid <br />Date of Payment <br />Payment Type <br />Receipt N <br />Check M <br />Recvd tlr ;w <br />�Q L8 SUPV �� /_J— ACCs _f.._I�__y„�_ <br />UNIT CLK <br />J <br />