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NN.t/ SERVICE REQUEST <br /> (SERVREO) Revised 8/23/93 <br /> FACILITY ID # 1.�5�(1.1.7� RECORD 10 # / y 1�5 �'� INVOICE # 03070 <br /> FACILITY NAME CCL-AAJJ�� , 1 Lll`yw\,�.� BILLING PARTY / <br /> SITE ADDRESS .` 1— <br /> CITY s �CT/` -_-_ ..._-_ CA ZIPGe.� R�� <br /> P.WNFR/DPERATOR ` .JCJU�IS�.r u�..KPILLING PARTY N <br /> DBA PHONE #1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY yS+or��v� STATE __I::A ZIP q�� <br /> EAPN # — Land Use Arpiirntion # --- <br /> _-- —_—_ __ -_---- - BOS Dist ILocation Code <br /> !:ONTRACTOR and/or iyyp <br /> FF.RVTCF REOUESTOR IL"1_ ij(� 2�1(Jl/}�Yf NA.teh'LYR�j_. _ BILLING PARTY Y / N <br /> DBA ��1 PHONE #1 (&a) 317- _ <br /> '+AILING ADDRESS J'd_i7(Il f,W.9 ( _T�B�I SCp p, .�'JFFAX 0 <br /> CITY f..Q// STATE /'F ZIP l� e0go <br /> RILLING ACKNOWLEDGEMENT: 1, the vtdersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/Elm 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 /> ) also certify that 1 have prepared this application and that the work to be performed will be done in sqMdf 1-all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standar , State Federal Laws. <br /> APPLICANT'S SIGNATURE : in 1 3 1996 <br /> SAN auAQUIN COUNTY <br /> Title:, j CA.�i _ _— Oate:_(p �'! /Q �e eu:@In ,1.- <br /> —i -��cALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIION <br /> AUTHORIZATION TO RELEASE INFORMATION: In Addition to the above, when applicable, 1, the owner, operator or agent of same, o <br /> the property located at the above site address hereby mthorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAOUIN 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: A Q Service Code r <br /> Assigned to Employer # !' c? Date <br /> Date Service Completed / / -, _ Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Paywllt Payment Type Receipt # Check # Recvd By <br /> ----U <br /> AC �O/ I`I / UNIT CLK <br /> 1 <br />