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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # /'7 / / <br /> INVOICE # Il?. 7 <br /> FACILITY NAME `.7 G1.) �LL!)J V E �EV E►.� BILLING PARTY IJ JY.// F? <br /> SITE ADDRESS (� 43 ef"tI i I uLrre <br />' CITY S-IGLk-To►J CA ZIP 1�- <br /> OWNER/OPERATOR —TKL6,1JL IaP BILLING PARTY Y / (� <br /> DBA ;}..^�1 PHONE #1 (�lU ) (p.3 - 2--7 11 <br /> ADDRESS 962-0..66F12, (��Iz( './`I�J1+ ZJ <br /> . �� '1 0 q J, PHONE A2 ( ) <br /> CITY Yle^-5ptN�'-N STATE C zip 1+788 <br /> �APN # p Land Use Applicatian # <br /> 777 I BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR F-14- T�(� lia - <br /> BILLING PARTY / N <br /> DBA ��• ^• L tJC.S��(G'�{J " µ PHONE #1 <br /> fl <br /> MAILING ADDRESS ows Ayr /# .5Og- �li <br /> FAJ( # ( )AL- <br /> CITY <br /> fD too - �10�19 <br /> CITY Ste►'-AF�t�►.rl� STATE ... 1 ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/END 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 /> I 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 Slander Stat; and Federal laws. O6�'`��YI EWI <br /> RECEIVED <br /> APPLICANT'S SIGNATURE <br /> �A JAN 15 1997 <br /> Title: 1llgvna-r Date: Il`IICASAN� <br /> �qI IIJ.JOAQUIN COUNTY <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owMrvI�PQDhi.=I'tltO0F0#LeT0njE8VIU-*, of <br /> the property located at the above site address hereby authorize the release of any and all resin tUa,IVI�AI� ��� , <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. <br /> Nature of Service Request: �r� .a.�,-„�: C3.a,� 1 ,r•, ' Service Code 7 <br /> Assigned to 0 Employee # �j �} Date LZE17.97. <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT .„3 t% ;� <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Reovd By <br /> i <br /> _LLLtL <br /> 7 V / I <br /> REHS 1 .r'/_�/ SUPV / / ACCT __/ /� UNIT CLK _/ /_ <br />