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12/09/98 16:33 N0.078 PO4 <br /> Q1-17—i9°b 85:3-7AM SCM TO 789=6426 P.02 <br /> I� <br /> SERVICE REQUEST (EN 00 611 Revised 8/U/93 <br /> fACIL1IT ID / RECLRD IO # INVOICE 0 <br /> FACILITY MAW pr _1G` – BILLING PARTY T <br /> S1 Ti ADDRESS <br /> CITY _ �klyC �c� CA ZIP <br /> GNIER/GPERATGB <br /> Dan --— ' �J " PNGatE itt t Z� },;Z'.,�. LS�.•� <br /> I r _ �\_ t <br /> ADDRESS `� �S` .: '�., C PHONE #2 (1\Q <br /> CITY STATE 21P <br /> APw # use Apps,Qst i on # <br /> So Dist Location code <br /> CONTRACTOR arWor <br /> sERY10E REGIlESTpt - --- r Cb �(•/� BILLING PARTY / N <br /> j A <br /> DaA PHCNr #1 C -5,Ci) <br /> MAILING ADDRESS FAX # c S(�: �� gam_ gq,;-(s <br /> i <br /> CI77 �17 r\ �ti.NC i`�_ STATE ZIP Cr + T <br /> i <br /> BILLING AcX9u%ilfDGIDWHTt I, the udorsipned owner, operator or agent of s , acknowiadge that all site and/or project specific <br /> PHS/Mri0 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 fore. <br /> 1 also certify that ! her- pr-pared this 1 Ucation �- rk to be perfamaad will be done in actordwce with at SAN <br /> JWGUIN CC�tJNTY ardi" Codes and it and iec "t taws. <br /> APPLICANTIS SIGNATURE rl a <br /> Title: LOI\cC h– \�r�� Date: 5� �C���`�. <br /> AUTHMIZATION TO RJVA$j INPGRNATICN: in addition tc the above, when applioable, I, the owrwr, operator or spent of ansa, of <br /> the property located atIthe abated aft@ addrp@ heretrr authorfzv the reifese of any and all results, peetseMlost data and/or <br /> ww1foloom l/site esasasment infoi tion to SAN jcA0UtN COUNTY PMLIC NBALTH SERVICES MIRON)MUL WL7K DIVISION as sore as <br /> It to available and at Jhe some t1aw it is provided to ee or wY reprosentstive. <br /> Nature of Serviee Rawest: Service Code <br /> I <br /> Assigned to FJrpltywe # Oats <br /> I <br /> Date Service Comptated /–_ f Further Action Required: T / N PROGRAM ELEMENT <br /> Fee Aeccmt Avwmt Paid pate of Payment Payment Type Receipt $ Check M Rvuvd By <br /> t <br /> RENS �J��f.w@ Si1P1► ��J ACarI __f�� UNIT CLk /`J <br />