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FACILITY ID # I ()039,6-5 <br />!Q39,6g I RECORD ID # <br />1vU. d3zo <br />FACILITY NAME <br />INVOICE # <br />✓.032019 <br />CEN 00 61) Revised 8/23/93 <br />— -- Y BILLING PARTY I Y / N <br />SITE ADDRESS 1413 BOURBIZI STIREEN <br />CITY SPOCKION CA ZIP <br />OWNER/OPERATOR PACIFIC BELL BILLING PARTY Y / N <br />DBA PHONE #1 ( 510 ) 823 - 7777 <br />ADDRESS PO BOX 5095, RM 1N200 PHONE #2 ( 415 1331 _ 0924 <br /># <br />CITY SAN RAMON STATE CA zip 94583-0095 <br />F <br />Land Use Application # <br />BOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REOUESTOR PACIFIC BELL <br />DBA ATM: RICHARD JOHNSON <br />MAILING ADDRESS PO BOX 15038 <br />CITY <br />` M' • ID • <br />STATE CA zip 95851 <br />BILLING PARTY CyY " / N <br />PHONE #1 ( ) <br />FAX # (—)-- <br />STATE <br />)- <br />BILLING ACKNOWLEDGEMENT: I, 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 wit[ 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 acco{V"etljJ l SAN <br />JOAQUIN COUNTY Ordinance Codes and standards, State and Federal laws. RECEIVED <br />APPLICANT'S SIGNATURE <br />Title: PRO= MANAGER/ARONSON ENGINEERINGJN(3ate: 8/19/96+N JOAQUIN COUNTY <br />')-" U HEALTH SERVICES <br />' EN�IIR;':PoGni- <br />�V. r <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator dr'"a¢an£O#IsLMep14151ON <br />the property located at the above site address hereby authorize the release of any and at[ results, geotechnical data and/or 1 <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br />it is available and at the sane time it is provided to me or my representative. I-rw , i / 9 <br />Nature of Service Request: <br />Assigned to <br />Employee # <br />Service <br />Date <br />Date Service Completed _/ / Further Action Required: Y / N I PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvc! BByy—/ <br />WV�(yC0 <br />/_ <br />1 /1UNIT <br />CLK <br />v <br />RENS <br />_//_ <br />SUPV <br />_//_ACCT <br />/ <br />/_ <br />1 /1UNIT <br />CLK <br />Ell <br />