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MmITY I # <br />FACILITY NAME <br />SITE ADDRESS <br />CITY <br />OWNER/OPERATOR <br />DBA <br />ADDRESS <br />CITY <br />PAPN # <br />SERVICE REQUEST (EH 00 61) Revised 8123/93 ,- <br />RECORD ID # I - I INVOICE # I <br />CA ZIP <br />STATE <br />Land Use Application # _ <br />ZIP <br />CONTRACTOR end/or L 1 �� ,-(h <br />SERVICE REQUESTOR �jr l< \ �LJ(ruJ ,IYyV(�,.� 1 �- C,A , <br />DBA <br />MAILING ADDRESS <br />CITY <br />BILLING PARTY Y / N <br />BILLING PARTY Y / N <br />PHONE 91 ( ) <br />PHONE #2 ( ) <br />BOS Dist Location Code <br />BILLING PARTY `7 Y / N . <br />PHONE #1 (2-07) <br />FAX # ((?r -)J( ) d .]L- S (SL <br />STATE `. ZIP ( <br />BILLING ACKNOWLEDGEMENT: 1, the urdersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PNS/EHD 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 will be done R MmIg Dh all SAN <br />JOAQUIN COUNTY Ordinance Code Standards, State and Federal laws. <br />DEC 13 1.05 <br />APPLICANT'S SIGNATURE : M —� <br />SAN uT� <br />I pS�PLFBLIC HEALTH SERVICES <br />Title: ` M� ` 1 A-, Date: � Z' � � ! ENVIRONMENTAL HEALTH DIVISION <br />WRIGHT ENVIRONMENTAL SERVICES, INC. <br />CORPORATION HEADQUARTERS <br />BUS. LIC. NO. 651501 <br />4220 COMMERCIAL DR., NO. 5 633-0756 <br />TRACY, CA 95376 <br />THE <br />DER OF <br />Bcu:k`fVrockt <br />TRACY C)MCF <br />IIT" I—' Rhd, llu-,. CA 95376 <br /> <br />— 19 �� <br />DOLLARS <br />