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' • SERVICE REQUEST • (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # � 793 RECORD ID # V'`� INVOICE # <br /> 11 LEAf2NEl2 /�1 <br /> FACILITY NAME �f'N G� I ,/ J `�-�()"��1`-I� BILLING PARTY Y / N <br /> SITE ADDRESS 7�II I�l'PCV'I D21dr <br /> CITY l CA zip G152o10 <br /> OWNS /OPERATOR T 4r LEArRNEk `Q' "\/ BILLING PARTY QQ�µ'�1ftO / N�V[ <br /> DBA `/ ,/� PHONE #1 ( ZO )y' '3q I O <br /> ADDRESS Z._TI I�If't IV7 �FjVC /. PHO/NE #2 ( ) <br /> CITY � 1 bd<T ,�F STATE CA zip <br /> APN # p Land Use Application # <br /> I805 Dist Location Code <br /> CONTRACTOR and/or <br /> BILLING PARTY <br /> SERVICE REQUESTOR <br /> DBA C• PHONE #1 (�^DQ�)�'-5 - rr,509 <br /> MAILING ADDRESS p )4- I.iO Ploo --4, FAX # (n ) -� 11365 <br /> CITY /lSPc1—IA STATE CA- ZIP 9327'7' <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> I also certify that I have prepared this application awork to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, Stat ral aws. <br /> 1� <br /> APPLICANT'S <br /> SIGNATURE r.1 ,�,1 ,l. <br /> Title: L/VV)IL-��MGN ✓nt"� ftN�CT E/�— Date. / <br /> it:25•F.z. . <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agenb.Rf�same, of <br /> the property located at the above site address hereby authorize the release of any and all results, ,RIORh i I data and/or <br /> environmental/site assessment information to SAN JOAQUIN <br /> COUNTY PUBLIC HEALTH SERVICES ENVI RONMENfAI, HEALTR'DTV Y51 ;as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> ��� �� ��/( (j L lN� service Code <br /> Nature of Service Request: I }� <br /> Assigned to �. � 1 Employee # � (1`l Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT —w <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> -L— <br /> sUPV _/ /_ ACCT / / � UNIT CLK _/_/_ <br />