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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID <br /> RECORD ID # 0/ 3 <br /> # / ' C n 1 <br /> FACILITY NAME ��/7l ✓ /N K"'�lNe- BILLING PARTY Y* / N <br /> SITE ADDRESSC.. � IV� �o�� �/.�/� <br /> CITY 10 CA ZIP 1 �l/� <br /> OWNER/OPERATOR L S1,1 4DUNc' Car r BILLING PARTY Y / N <br /> DBA tey� PHONE #1 ( �) . Ino— <br /> ADDRESS <br /> 0'11 I N GS7�—M C—t- � PHONE #2 ( ) <br /> VV l <br /> CITYSTATE <br /> —APN # p Lend Use Application # --'� <br /> I /� DOS Dist Location Code <br /> CONTRACSERVICE RE and/or ' I n� LIAA / z� ^ (1 <br /> SERVICE REQUE STOR IVpI`C ,� c ^�/p t� `1L I{�/�t�_ J� BILLING PARTY Y <br /> DBA � hX1 \I4-9bCI.IP �� �do,_ 6 L% �` J HONE #1 <br /> 1Z" FAX # ( ) <br /> MAILING ADDRESS I Le <br /> CITY _ J:�D6A,4AJA STATE C_.&— ZIP Q(0(0 <br /> BILLING ACKNOWLEDGEMENT: I, 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 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 Ordinan Codes and Standards, State and Federal laws. PAYM j <br /> APPLICANTSIGNATURE <br /> Rj�._ Date• / �- 291997 <br /> ` <br /> AUTHORIZATIONTOTO RELEASE In addition to the above, when applicable, 1, the owner, operty1�VS'�0A0Lffi�yf,�d5U�fplfCysame, of <br /> the property located at the above site address hereby authorize the release of any and all rest�lgACi17T1vElt�ltEt`fPDs§( Qor <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. (I_ <br /> �c7 L7" Service Code � 0 <br /> Nature of Service Request: � �. / <br /> Assigned to g5 • / &1i�°`"Y p <br /> � �� ��q Employee # Jf�� Date 7/ e2/ / `,"7 <br /> Date Service Completed _/_/_ <br /> Further Action Required: Y / N PROGRAMELEMENd3n <br /> Fee Amount Amount Paid �IDate of� Payment Payment Type Receipt # f chheck # Recvd By <br /> V <br /> 7dY• L��OO,�O <br /> RENS Y�/ Z Fr SUPV _/_/_ ACCT I�\ IJI '- 7 / '�?T� /y^ UNIT CLK _/_ <br />