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DEC— 6-94 TUE 9 : 16 M&rl HERTIHU, H/C SER CO. 209 9828446 �• '-`� <br /> SERVICE REQUEST JSERYREOZ Revised RM/93 <br /> ITACILITY ID N n c RECORD ID I 1 <br /> IA.clLI1Y RAMS 0- � CA ILLINQ PAot�Y" Y^I ! N <br /> SITE ADORES4 / ®D c � .V # "/ <br /> CITY f�L"/ / %/ L���. CA ;IP �� •G <br /> DIMER/oPERAToR 1eX JW1+ V1,:ffBILLING PARTY <br /> DBA `IVre/ 7(/['>�nf= p ) PHONE A) 70 <br /> f� ) p� . 0� <br /> ADDRESS ZOU J\�' //�-//'/ DI.L 47i� �1/J PHONE 02 f�V� ) /��• O�y <br /> CITY L T 1l�OY STATE rd; . :IP <br /> -- end Use Application R <br /> I LOOS <br /> Dist Locetlon Code <br /> rovAACICR and/or <br /> SFRVICE ( lam REOVESToR//J� 09 l �/%�J� a/01 � j`- /� BILLING PARTY Y / �\ <br /> DBA /40r C/771W2%X17-f //�6�yT/�oL/U� T` PHONE /t cE0 <br /> t,(�A�•.S`'``� <br /> NAILING ADDRESS � �-'o S E— ,�(/ /✓ 97 FAX I f ) <br /> CITY STATE IIP Zj2-y7 <br /> BILLING ACKNWLEDGEMENTt 1, the undersigned owner, operator or agent of same, acknowtedge that all site and/or project specific <br /> PHS/EHO hourly charges associated with this facility or activity will be bitted to the party Identified as the BILLING PARTY on <br /> Paye T of this form. <br /> I also certify that I have prepared this appticotion and that the work to be performed wlil be done In accordance with alt SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standar. , State and Federal, laws. <br /> ArPLICANTIS SIGNATURE I <br /> Titte: Date: • ! <br /> AUt HORIZATION TO RELEASE INFORMAT10Nr In addition to the above, when applicable, 1, the owner, operator or agent of Same, of <br /> the property located at the above site address hereby authorize the release of any and alt results, Seotechnical data and/or <br /> envirormental;alte assessment Infammatlon to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION K soon u <br /> It It avallnble and at the Samm time it Is provided to Arc or my representative. / g T n <br /> NaWre of Service Aegxete <br /> rlP R1•!JF G-+�� - �1�/�o�.C2C�d f-�,-F'°C SetVlef Coda -L <br /> Assigned to EffpLoyee I Date <br /> Date Service Coapteted C /�_/ Further Action ReQUiredi Y / N PRocAAN EIENENT a3 �C� <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt I Check I Recvd By <br /> O <br /> IBM I <br /> RFNS "/,J` SUPY /�/_ ACC71 UNIT <br />