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rKm�q rTrz <br />SERVICE REQUEST <br />FACILITY IDH lJ <br />RECORD ID N 0 JG IF5 1 INVOICE N <br />(EH 00 61) Revised 8/23/93 <br />FACILITY NAME /'t�� "'"' BILLING PARTY I /1/yO / CN/ I <br />A 5T K <br />SITE ADDRESS <br />CITYC-����CCA� 2tP <br />::�. • -� _ ,, BI LLINC PARTY T / N; <br />OWNER/OPERATOR <br />PHONE 01 (-7 +) b'x-�-�CC� <br />DBA/ 00 <br />/4 cT ✓jam 'Z— ID(Z . PHONE t2 (�),�(y' <br />a,1 ADDRESS T /^ /M <br />CITY i •`4���A STATE `A ZIP <br />—APN IT _— pLand Use Application N <br />ter c-v�G AOS $7' '75 I — BOB Dist Location Code <br />CONTRACTOR and/or� \ BILLING PARTY Y N <br />SERVICE REQUESTOR <br />PHONE 01 <br />DBA { ( 9X(4:7) W6-• <br />-? <br />&AVr "5C FAXN <br />MAILING ADDRESS e <br />CITY C—A ZIP / � <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific <br />PIIS/EHD hourly charges associated with this facility or activity Will be billed to the party Identified ,ase the: BILLING PARTY on <br />Page 1 of this form. <br />d <br />r� aY U l r <br />I also certify that 1 have prepared this application and that the work to be performed will ben c o e with ell BAN <br />JOAQUIN COUNTY Ordinance Code Standards, St Federal laws. ;r;d JCiHWuiiv ll <br />!!!!C( -/j IC HEALTH SERVICE` <br />APPLICANT'S SIGNATURE <br />,� i ,�7�."�l1gkLiTAi HFAI TH nlyisi. <br />Date: 2--Z-1 � <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator ore same, of <br />the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br />environmental/site assessment information to SAN JOAOUIN 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 />L,. _. /in Service Code <br />J� �h <br />Nature of Service Request' <br />Assigned to 1' �� L[� fTA�4-�-y Employee N — <br />Date Service Caipleted <br />Further Action Required: Y / N <br />_/ / <br />Fee Amount P <br />Amount aid Date of Payment I Payment Type Receipt N <br />MEMPO ' <br />Date_/ <br />PROGRAM ELEMENT <br />Check # ' I Recvd By <br />UNIT CLK I <br />