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' l.r SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # /'�,, � (1��RECCORD��I1D # - INVOICE # 4j <br /> FACILITY NAME ShRil '0('i{ yic6 SfA � o/1 BILLING PARTY Y / N <br /> SITE ADDRESS Soil W/.yl���vi, ✓I�aM� kDl+ tri <br /> CITY 1S�0�i1C.l U✓� __ CA zip <br /> OWNER/OPERATOR toll Dd C1/F/ oyiV BILLING PARTY / N <br /> DBA I n {� }- n� PHONE #1 ( 510 )1pE - ,I fojo/ <br /> ADDRESS /1�t0 1jQ 111 7 Y RI/f• i �I�.i IPI �u/ //,�1 nPHONE 92 (�) 010 - W'41l <br /> CITY NVil,Ord STATE (Q_ ZIP -1�f20 <br /> APN # FLand Use Application # <br /> BOS Dist Loceti on Code <br /> CONTRACTOR and/or /�� � L <br /> SERVICE REQUESTOR K E L�Lw i 6yi 1' a1 O VI BILLING PARTY I �-�Y �{/�q0� <br /> 771 <br /> DBA n 1' / y, PHONE #1 ( 1516) )�L1",�I- - VII <br /> rA <br /> MAILING ADDRESS Zj`T (fi 1Q/ d-1001C (.burl 014'546, <br /> � /' 1 /FAX # (1J-�—) - - q 2' <br /> CITY l0- r0 Valley STATE C_ zip 01 :J`� 6, <br /> Valley <br /> BILLING ACKNOWLEDGEMENT: 1, 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 the party identified as the BILLING PARTY on <br /> Page 1 of this form. <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. ?mm him ti <br /> APPLICANTS SIGNATURE .j 1996 <br /> Title: G ���N — CZ-- Date: 2 <br /> 5 N JOAQUIN COUNT? <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 4h a4VeF+E)Rp",it9L'MCeant of same, of <br /> the property located at the above site address hereby authorize the release of any N%'d'.gt4\MMUt*sN9RWtpahnlr:aAll ata 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 time it is provided to me or my representative. <br /> Nature of Service. Request: 2 Service Code <br /> Assigned to _a3a..>9�� G .� Employee # _ Date <br /> Ld_ <br /> Date Service Completed �_/ / - Further Action Required: Y / PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> UNIT CLK _/ /_ <br />