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CITY T Rq/ <br />STATE <br />SERVICE REQUEST <br />9 sM <br />Revised 8/23/93 <br />FACILITY ID # <br />jooz.o� <br />RRjE/COR/qD/ ID # <br />NVOICE <br />/ <br />FACILITY NAME <br />6e/fGL <br />P1. T <br />BILLING PARTY <br />Y / N <br />SITE ADDRESS <br />is -,ST/z�/=E <br />Location Cade <br />CONTRACTOR and/or <br />CITY <br />/ /i�L y <br />�7lfF <br />CA ZIP /5.3 7,!� <br />ca <br />SERVICE REOUESTOR l/`�'4L LY�� <br />OWNER/OPERATOR <br />c ry QI <br />� <br />Y / <br />N <br />DBA <br />PAOLV`MrT <br />-'I <br />PHONE 91 t ) <br />PHONE #1 <br />ADDRESS <br />/� <br />SZD / /LR<</ AL-d/J' <br />PHONE #2 C ) <br />CITY T Rq/ <br />STATE <br />E/4 ZIP <br />9 sM <br />gPN9 <br />p Land Use Application # <br />jooz.o� <br />/o a/ 03 <br />C�yI(x <br />!! <br />IBOS <br />Dist q <br />Location Cade <br />CONTRACTOR and/or <br />ca <br />SERVICE REOUESTOR l/`�'4L LY�� <br />lsc-(YNMYvf%TjI� <br />SEiQULC�=S _LNG <br />81LLING PARTY <br />Y / <br />DBA <br />PHONE #1 <br />MAILING ADDRESS N1 H1L6 U' -CG(/ W/l % FAX # ( 1611 ) fS2 '= A' _ <br />CITY T2AL. STATE (-,,4 ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersignedow leer, 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 identifi ea as the BILLING PARTY on <br />Page 1 of this form. <br />I also certify that I have <br />JOAQUIN COUNTY Ordinance C, <br />APPLICANT'S SIGNATURE <br />Tit <br />this application and that the work to be performed will be done in accordance with all SAN <br />tancIr/J�/j State a Federal Laws. 7 o'k <br />11 <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when appticabLe, 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, geotechnicat data and/or <br />environmenta(/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: <br />i <br />Assigned to ')f1ft + l Employee # <br />Date Service Completed _/ / Further Action Required: Y / N <br />Service Code <br />Date <br />PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type Receipt # Check # <br />Recvd By <br />/ooa.o, <br />jooz.o� <br />/o a/ 03 <br />C�yI(x <br />REHS _/_/_ SUPV i _/_/_' ACCT \�/� .� / l� �� UNIT CLK _jam_ <br />