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SERVICE REQUEST • (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # 642a Q 2Z/ RECORD ID # l(/�3 ?�Z) INVOICE # <br /> :Emc Y lJ <br /> FACILITY NAME �` `�,, 1 ��� c �1 I BILLING PARTY <br /> SITE ADDRESS <br /> CITY \VJI� W ( CA ZIP _1 J <br /> OWNER/OPERATOR �1nP 0 \ 1 CS1o'`,Ilu lA BILLING PARTY <br /> y / N <br /> DBA PHONE #1 (? VCo ) "i -n":j Ss— <br /> ADDRESS; e9z�b//^yy I �(JI I I � U 1� lij ` /P�HONN�E #2 <br /> CITY ./e lA STATE , ZIP <br /> �"/ <br /> �qpN # Land Use Application # BOS Dist Location Code <br /> CONTRACTOR and/or 71 BILLING <br /> SERVICE REQUESTOR \•, V �� Y�_C,CL1faCZ n`1S (\f_ , BILLING PARTY Y / <br /> DBA PHONE #14L <br /> I - S3 <br /> MAILING ADDRESS - `� '1�L1�Y'1 \i � 1 \31C �'F\AX`# (�TFI A' I - Ina <br /> CITY 1l: I ' STATE l I ZIP l (JCi1� GC• ve® <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all si a / Iay?ect specific <br /> PNS/EHD hourly charges associated with this facility or activity will be billed to the party identi§W as the BILLING PARTY on <br /> PUBLIC <br /> JOAQUIN Co <br /> Page 1 of this form. ENVIRONMENTA��HEA�V'CES ON <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLI CANT IS SIGNATURE :�� 4 ���1 �-p_ <br /> Title• Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: n 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 /> environmenta L/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: o Service Code <br /> Assigned to �� �� j2il:� Employee # 20 Date <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 /> c,,), a V 8 iy 97 v iagr, Abya, <br /> REHS C, / /T'E SUPV _/_/_ ACCT14. <br /> / /"1 ' 1 UNIT CLK _/_�_ <br />