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SERVICE REQUEST <br />FACILITY ID # RECORD ID # © I J 6 j ✓ INVOICE # <br />(EH 00 61) Revised 8/23/93 <br />FACILITY NAME, '��rLe \A Y" ��TtT� BILLING PARTY Y / N <br />l <br />SITE ADDRESS <br />CITY 4�T65ZAt4T&A CA zip <br />OMR/OPERATOR /1tf��+�+ 1`� I_' '�('�`�(}� �/y�`, BILLING PARTY � / N <br />DBA RIM 6� ZC� �^v" ��•`� t �f PHONE #1 (D(5�1_)LW4 -1436 <br />ADDRESS —'TZ <br />CITY fav` <br />APN # <br />1>3 - I RD <br />STATE <br />Lard Use Application it <br />PHONE #2 ( ) - <br />21P 3b -,b j <br />BOS Dist Location Code - <br />CONTRACTOR and/or <br />SERVICE REOUESTOR(I����L--�77J�+V�F'`Nn4—\D k -1(r 74-7 �_�tn, (� �O BILLING PARTY �(y Y (�/��Y- <br />DBA VC+L� I Cl�-+M v __T�1, �C� 1`T r 1 1 `-^" S(A r'- , `� PHONE #1 ( ) n 1 ( -_.7-1 51 <br />MAILING ADDRESS'VV/��� f�- FAX # (_)Z - <br />CITY C) P*'v 't�YLAE STATE ZIP ^1 75)D I <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS/EHO hourly charges associated with this facility or activity will be bitted to the party identified as the BILLINGLLPPAAR( an <br />Page 1 of this form. ',5 Y1YA <br />1 also certify that I have prepared this application and that the work to be performed will be done in accordance with nll V <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. r CFP 3 A <br />Date: `7 - d.7 - K X <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 ay representative. <br />Nature of Service Reegyueesst_UA5.7 1G��i�KkNV�-(1\J <br />Assigned to l`-t✓y �( �tI 1 Employee # <br />Date Service Completed _/_/_ Further Action Required: Y / N <br />Service Code <br />Date <br />fy <br />PROGRAM ELEMENT . - <br />REHS IY1 �_/ - / L� I SUPV I / / I ACCT I _�_/. (UNIT CLK I <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />REHS IY1 �_/ - / L� I SUPV I / / I ACCT I _�_/. (UNIT CLK I <br />