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J <� S SERVICE REQUEST , (EH 00 61) Revised 8/23/93 <br /> FACILITY 1D # C p (/� / RECORD <br /> r ID # ��J/ z , INVOICE # <br /> FACILITY NAME �lq(//0 �/lt, JC/{ l;a'� LII- � d / BILLING PARTY Y / \N <br /> SITE ADDRESS I l �•a•I r�Q 2rj� _ �-' <br /> CITY �af tirU ,� " CA ZIP <br /> OWNER/OPERATOR ��." E l U S�(7MEK Co BILLING PARTY YO / N <br /> DBAnn ( ( I(it IC < PHONE #1 ( ) - <br /> ADDRESS /_ OM L)X ^ � b v II <br /> PHONE #2 (707 ) 7-IS- Chi <br /> N O 9� <br /> CITY D1 "1 STATE �R• ZIP I7 S1� <br /> p APN # FLand Use Application # <br /> r <br /> f L 805 Dist Location Code <br /> CONTRACTOR and/or PE 6-0 FdM G `� �/�MEM ��y <br /> SERVICE REQUESTOR l � BILLING PARTY / N <br /> DBA /'1 1 If Q'7 ( l l PHONE #1 (z9 0 ) 276 - <br /> fJ(/ (, �cF, <br /> �QkLI/ <br /> MAILING ADDRESS /"—� /yr/O�1 G J /� pFAX # (2.09 ) z 76 - � 0 <br /> CITY f/ S'M b STATE ( ZIP -L �7 / Z <br /> BILLING ACKNOWLEDGEMENT: 1, 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 will be billed to the party identified as the B LLI)LG-PARTY._O(1\ <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to bg if ((SRI�t��ne i accordant with all SAN \1 <br /> JOAQUIN COUNTY Ordinance Codes and Standards State nd ede nal s. U GTO V <br /> APPLICANT'S SIGNATURE/: <br /> Title: 1 I/Ni�2L(�.l�t/(. Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator ��� Eof <br /> the property located at the above site address hereby authorize the release of any and all results, geoteeMlPCallM data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALT�IARIJ� 1eH,")L3 0TI as <br /> it is available and at the same time it is provided to me or rry representative. PUBLIC NTEAAL HE SERVICES <br /> SION <br /> Nature of Service Request; ��pn� q Service Codey 3 <br /> Assigned to -ij�-�!`�' \t I n 1�� 0 Employee # q 7� Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT ?• Yl <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 767(, <br /> FENS C,�i�/ SUPV /_ ACCT _/ / UNIT CLK _J_f_ <br />