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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> E FACILITY ID N RECORD ID NI,33 S 0 INVOICE N <br /> F <br /> FACILITY NAME 1l 11 1, 1 �d 1 111 I� I BILLING PARTY 40/ <br /> SITE ADDRESS Pa,(L <br /> CITY <br /> 1 VJG \ "1 CA ZIP 5 <br /> IY OWNER/OPERATOR �11 1\P \ 1 � , �I I� I11A l� BILLING PARTY Y / N <br /> DBA �/y��( �„�/1I 't PHONE #1 (r00 )I iI`Y <br /> ADDRESS �p�//11__,_()IIJII 1' 9w I� n /PHONE #2 ( ) <br /> CITY �1 IA 1( STATE ZIP <br /> APN # -- Land Use Application N -Ii— <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUES70R <br /> i DBA /�T�yr� `�/'1 PHONE #1 - .L— <br /> MAILING ADDRESS !/� cl✓ 11���111 \) �.J� /FFA% # <br /> ` CITY �� ZIP <br /> ` STATE <br /> k <br /> �[ BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site end/or project specific <br /> ff PHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on ' <br /> Page i of this form. <br /> I also certify that 1 have prepared this application and that the work to be performed wilt be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes LCand Standards, State and Federal taws. <br /> APPLICANT'S SIGNATURE <br /> f z <br /> Title• Date:�n�-�� <br /> i <br /> AUTHORIZATION TO RELEASE INFORMATION: n 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 /> f 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 my representative. <br /> Nature of Service Request: Service Code <br /> Assigned to Z) wi94::zn� Elip,oyee # '�3 Date -t-/i-q--/-` '-a <br /> f� Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> 1 <br /> F <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check N Recvd By <br /> r� <br /> RENS /�/1L SUPV _/__/__ ACCT _,/_/_ UNIT CLK _/_/_ <br />