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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> CILITY ID # RECORD ID a 5 dr INVOICE # <br /> FACILITY NAME d(/.IZ U`Q.-1 2 CG�i C>r-) \ ,,CC)I'\� r BILLING PARTY Y / <br /> SITE ADDRESS q Q' <br /> CITY I /` g., � 1 CA ZIP 1 <br /> OWNER/OPERATOR O'e'OD� 11 f7C6 rT�.� //O n BILLING PARTY p'�CY /� <br /> ORA DR LAK_` �/�')C G n ox Q-1'� PHONE #1 ( )ALL- T I Lf T-V <br /> ADDRESS P� J "� �SG S S C�h �" y y� PHONE #2 ( ) <br /> CITY ��� C STATE 21P <br /> APR # p Land Use Applicet On # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR yG}�o�Jn 5 �YL '�21� !Jr j SW'Q�� BILLING PARTY / N <br /> DBA 6 O-4 U & PHONE #1 (9/�) l'I - 93 S <br /> MAILING ADDRESS -5n� (I I S /o /4/"`-- l rC � �` 'AX 3 42 0 <br /> CITY � �UIa GL t'J �( /( ` S STATE ZIP / /-7 / U <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EIID 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 1 have prepared this application and that the work to be performed will be done in accordance with a l SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standarrd/d77s,r State and Fede an <br /> Federal laws. YMEND <br /> APPLICANT'S SIGNATURE :� Q' �i `-'v <br /> 11 p / .iNN <br /> � " .b 19ytt <br /> Title: $\G\ SLt pJ2(' (� L5,o Date: CO ' SAN JOAOUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, oper~r6iNW§bg6Ld1E/gdihi•911691ON <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data 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: Service Code <br /> Employee a <br /> Assigned to ;�t=q � 3 <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT C:`E-� <br /> Fee Amount Amount Paid t of a nt Payment Type Receipt # Check # Recvd By <br /> ° Vf �' <br /> REHS SUPV _/_/_ ACCT ,�/ —/ UNIT CLK _/_/_ <br />