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-W SERVICE REOUEST-, IAJ p r (SERVREQ) Revised 8/23/93 <br />FACILITY ID N <br />Amount Paid <br />RECORD IDN <br />-7i INVOICE N <br />Receipt N <br />C j j n ` ' �{� ` y�T � vw - u.t.- <br />rACILIrY NAME SJJL>, -' 1 6P-\J�)Ct—'/�/Lq�+p��F'�,�1 ACM '�T'�/�� ` 1tg BILLING PARTY Y / N <br />SITE ADDRESS 3011 UJ/ JAMItJ oul- (✓�r-IyG <br />CITY S-TaCK---M I CA ZIP 15209 <br />MfJFR/OPERATOR ? He L�L- OIL COM r)mA ( BILLING PARTY Y / N <br />DaA 30>< 4'o WILLOW <br />[ n1h1cfn �1/c/T� IC A G4 L�f�p52y r p� / /� Rxax! Nt c 51 f0� )��]�� G (00 <br />ADDRESS 1390 WILLOW _��SC 1V.A 1� �Ul1y� lliC/ RNDN! M2 f�l\/ 10 -6AG <br />CITY <br />WNC OS D STATE ZIP 4:5 G C <br />�ArN NLard Use Applieetlon N <br />r <br />— 80S Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REOUESTOR /'ll�l�y GN5 <br />t_.1 TrOP) E- N X11ihaBILLING RAR7Y Y/ �J <br />DBA <br />-2-1-84 <br />MAILING ADDRESS 6-7 UxcU�r� Couizr �y,[��'FAXX N (i)c) ),647 - 11 7� <br />CITY LIU IZM� _ STATE CR, ZIP I` 552 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of Same, acknowledge that ell SfRwa/er project Specific <br />PHS/EHD hourly charges aSsoclated with this facility or activity will be billed to the party ider16li Md2e>� the BILLING PARTY on <br />Page t of this form. of l 995 <br />� SAN JGAL,��„N_ .. <br />I also certify that I have prepared this application and that the work to be perfornedt-1� WG419pL�ij n"a with all SAM <br />JOAOUIN COUNTY Ordinance Cend Ste�rds� State y� Federal laws. <br />ods <br />I_ DS I Ll:. 91.,_,,.._ Nb7 <br />APPLICANT'S SIGNATURE <br />Ti <br />AUTHORIZATION TO RELEASE INFORMATION: in addition to the above, when applicable, I, the owner, ti <br />l <br />the property located at the above site address hereby authorize the release of any and ell result <br />environmental/site assessment inforsbtlon to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMEN <br />It is available and at the same tine it is provided to me or my representative. <br />Nature of Service Request: <br />T v <br />Assigned to I <br />Date Service Completed <br />Employee If Cf 71% <br />Further Action Required: Y <br />Service Code <br />Date <br />/ (N p I PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Peyarent Type <br />Receipt N <br />Check N <br />Recvd By <br />0 <br />c1 <br />REMS i _//I SUPV I _/_/_—I,j,CCT I _/_ /_I UNIT CLK I _/_/_ <br />