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FACILITY ID H <br />FACILITY NAME <br />SERVi CE REQUEST • <br />RECORD ID # <br />/n(dit r'• an",C �A2K <br />SITE ADDRESS 314 S .EAS I-OV61A <br />CITY 1.A:3(2oCP CA ZIP 9 <br />(SERVREQ) Revised 8/23/43 <br />INVOICE 0 <br />BILLING PARTY I Y / <br />OWNER/OPERATOR <br />MAWI< YAAA/ - <br />RYAN <br />r-l"I�Y —/�WSIT • <br />BILLING PARTY Y / <br />Check M <br />Recvd By <br />Fee Amount <br />ORA <br />AS 9130v -,E - <br />PHONE s1 ( ) <br />ADDRESS A'S /4.60✓C PHONE {2 ( ) <br />CITY STATE ZIP <br />APN C Land Use Application N <br />SOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR AfAL.GOc.l'1n�J— BILLING PAAR��TYY� q� / N <br />DBA �/�yAe- PL 14'f it PHONE 01 ( 91,6 /b a <br />NAILING ADDRESS Iib /0" c5`/�l=moi ��`�' fo �� FAX a p 6-7 <br />G2 <br />CITY S �c'u :O STATE ZIP 91� /F/u. .1D,2- 416�s <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS/EHO hourly charges associated with this facility or activity will be billed to the party Identified <br />as,Ia BILLING PARTY on <br />Page 1 of this form.�y�$�y�'tV°44.•x <br />oR'ana" <br />R 9 <br />1 also certify that I have prepared this application and that the work to be performed will n peeordehce with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, Federal laws. <br />Jb� r i�i.cS <br />APPLICANT'S SIGNATURE / $P,N u•r, 1,,,.I�g1QN <br />/A // vttB61C�'{sci4kpatri� <br />Ja,.-ej4,? , , l J - Date: /- r <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br />the property located at the above site address hereby authorize the release of any end all results, geotechnical data and/or <br />environtaental/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 Serrvvicce1 Request: 1 // / i �� CL U l-/ / Service Code _ 1�) <br />Assigned to l / A (7 I � !� Employee A `n Date / <br />Date Service Coapleted/_L/ l J Further Action Required: Y / N PROGRAM ELEMENT <br />(ACCT <br />Date of Payment <br />Payment Type <br />Receipt 0 <br />Check M <br />Recvd By <br />Fee Amount <br />Amount Paid <br />1�F6 <br />(ACCT <br />