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0 <br />SERVICE REQUEST <br />FACILITY ID # RECORD ID # U �! 9I INVOICE # <br />CEN 00 61) Revised 0/23/93 <br />FACILITY NAM VlJhl )NSoI,� N � � `n'-" BILLING PARTY Y / / a/ I <br />C_ <br />SITE ADDRESS ( SU`-' L-^'cl" /y� CEJ -7 <br />CITY LO � CA ZIP 1 ✓ LSI L� <br />OWNER/OPERATOR <br />DBA <br />�,p�oi., nN= C.al A• BILLING PARTY @�('Y / N <br />l <br />PHONE #1 INA)936 ZzoX <br />BILLING ACKNOWLEDGEMENT! I, the undersigned owner, operator or agent of same, acknowledge that ell 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 BILLING PARTY on <br />Page 1 of this form. <br />1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal taws. <br />APPLICANT'S SIGNATURE . <br />ao�� L. Of.�s -tp PAYMENT <br />Title: pio �F- co Date:.J� A DL 2 9 1997 <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br />the property located at the above site address hereby authorize the release of any and all results, gegSg",JLIM1W &r <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV IRONNENTA�HI 9W91HA'SFl4ML3§1W9 C*h <br />it is available and at the same time it is/provided to me or my representative. <br />Nature of Service Request: /G /iffS G`�/��1� Service Codef� y-5( <br />Assigned to zEmployee # <br />�10 <br />Date Service Completed _/__/ Further Action Required: Y / N <br />Date _�/ / 7 I <br />PROGRAM ELEMENT�7 Z9.] <br />Fee Amount <br />Amount Paid <br />` 70o <br />PHONE #2 <br />ADDRESS <br />(/�� <br />;0UAA <br />STATE � <br />ny 2 <br />ZIP <br />CITY <br />� `r <br />— APN # <br />p Lard Use Application # — <br />IBUS <br />Dist <br />Location Code <br />CONTRACTOR and/or <br />C n <br />I <br />N/J� <br />� I�QS <br />BILL ING PARTY <br />Y / N <br />SERVICE REQUESTOR <br />l`_ <br />�I\n'T T --- <br />X10 LoAie <br />bLIA.IC <br />PHONE #1 ( �) <br />DBA <br />,Z �� <br />C <br />`� t �J` "'� <br />[[,, 21 <br />FAX # (2Q$-) G21 -I oo-L <br />MAILING ADDRESS <br />P�/k-�J.'�JJ <br />STATE <br />�1 <br />ZIPQ /� <br />CITY <br />BILLING ACKNOWLEDGEMENT! I, the undersigned owner, operator or agent of same, acknowledge that ell 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 BILLING PARTY on <br />Page 1 of this form. <br />1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal taws. <br />APPLICANT'S SIGNATURE . <br />ao�� L. Of.�s -tp PAYMENT <br />Title: pio �F- co Date:.J� A DL 2 9 1997 <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br />the property located at the above site address hereby authorize the release of any and all results, gegSg",JLIM1W &r <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV IRONNENTA�HI 9W91HA'SFl4ML3§1W9 C*h <br />it is available and at the same time it is/provided to me or my representative. <br />Nature of Service Request: /G /iffS G`�/��1� Service Codef� y-5( <br />Assigned to zEmployee # <br />�10 <br />Date Service Completed _/__/ Further Action Required: Y / N <br />Date _�/ / 7 I <br />PROGRAM ELEMENT�7 Z9.] <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />3s� �L? <br />UNIT CLK <br />_/—/— <br />SUPV <br />//_ <br />ACCT <br />UNIT CLK <br />_/—/— <br />