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FACILITY ID # <br />FACILITY NAME <br />SERVICE REQUEST <br />RECORD ID IN <br />SITE ADDRESS :150 <br />1�F- j <br />CITYn CA ZIP <br />(EH 00 bt) Revised 8/23/93 <br />INVOICE # I "t.` <br />BILLING PARTY Y / N <br />�D t �ar�I�r}�� BILLING PARTY Y / N <br />OWNER/OPERATOR 1/' 1 y �t G� n <br />DBA l L�11ocol PHONE #1 (`1 i% ) 5513-7(471'Z <br />ADDRESS <br />/( <br />F�(n�l-t��y Ave <br />PHONE #2 ( ) <br />=-�,2Evrzmentc) <br />STATE 6A <br />ZIP qI ✓C, 01L <br />CITY <br />APN # <br />p Land Use Application IN <br />IBOS <br />Location Cafe <br />Dist <br />f7.,,. (�.,,,, <br />CG1ani�o (1f R141-VLL.7[Alt <br />/_�� <br />la <br />CONTRACTOR and/or <br />�a�ga <br />BILLING PARTY <br />N <br />c /.t,�y� <br />SERVIC__E R�OUESiOR <br />for TO`.gt <br />PHONE #1 (rJ�(�) - (D��../w� <br />DBA <br />�7 <br />13°1t� <br />rv1I'Ow <br />4,z FAX # ( 514 )�"(= <br />J,L[SL .— <br />MAILING ADDRESS <br />CITY WL `��%rd STATE CA ZIP 1452'0 <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 thepartyidentified as the BILLING PARTY on <br />Page i of this form. PAYMENT <br />1 also certify that I have prepared this application and that the work to be perfor�mcW �ul ll�done in accordance with ell SAN <br />JOA(,mu rrvmty nrdi,wnre Codes and Standards, State and Federal laws. nFc 16 1997 <br />APPI <br />Tit <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 tnm it in plvviu , Lu - - -w •-v <br />Nature of Service Request: 4,)t,- J1, -k ko-) Ffyy Service Code 3 <br />Assigned to K +-V-. Eoployee # /% �� V Date <br />Date Service Completed _/_/_ Further Action Required: Y / N PROGRAM ELEMENT -7303 <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />RENS / / SUPV / /_ ACCT <br />Receipt # I Check # I Recvd By <br />