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IACtLITY to / RECORD to e t ltLL1NG PARTY Y / N <br /> FACILITY NAME T8i hdl'� 6P��1 - •-'�� ,�'�` �..t• <br /> SITe MOAenn .r,.:... J3 _ ,.. /].)�C <br /> CITY Z-0 II CA 2IP <br /> P.T'ER/OPERATOR �_dj�/Aa CP / ltlLlNO PARTY ,.. Y _.. <br /> DBA vyM-�. - PRONE NF1 (92,4—)2-2-1fr"�"/D <br /> ADDRESS �/7S� W i , d1�T l� 1I2 ,,. PRONE lY.t ) <br /> CITY" /�"eSg O STATE ZIP <br /> APN m Census -----••-- BOS Dist LOOatten CON _- ` City Cede •----• <br /> CONTRACTOR andlor <br /> SERVICE REOUESToR t�/l..'1 1 /7 v/'/'Pi �nl /ilC lilumc PARTY Y . ! R <br /> DDA <br /> ,rte t <br /> HAILIHG ADDRESS �{.'C+�'�-tan ru� PSR ..,( ....) `--.G. L._— <br /> city Zed/i S7AtE �a' ZIP <br /> BILLING ACKNCULEOCEMENT- 1, the undersigned owner, operator Or agent of sal*, acknewtadde that *11 cite W*61' Prdiett apeelfid <br /> PHS/EHO hourly charges associated with this facility or activitywill+be bitted to the party Wan IWOW sa the MUM PARTY on <br /> Page t of this.EOMI. <br /> I nlso certify that I have prepared this application and that the work to be performed wilt "Fe titlhe it\ etledrr�le - Malt ail SAN <br /> JOACUIN COUNTY Ordinance Codes and (Standards, State and Federal taws. <br /> APPLICANT'S SI/ E <br /> CRATUR <br /> Title: SI.,.a'a: ._ �..8...y.�Aw:✓� IlaCat...�,7.,,`�r� un�: .,u.�.r�d C. <br /> r, <br /> AUTiIORi2ATtON TO RELEASE INFORMAYt6111 1n 'addition to the above, when applicable, 1, the OwSar,"Operstdr Gfu'"am of too,of <br /> the property teeatd at the above site address hereby authortte"fhe relaeee of any end At AWAte, "OteNIMItsl data and/or <br /> enviro ntat/elte essessment inforaation' to SAN JOAOUtO CoWf PIMLIC NEALTR SERVICE! 1ENVIMIMERTAL ROAI.tt btvttloo as Sao"aa <br /> it is evbItsbte and at the same tier It Is provided to me or eyyeaprefentatlw. <br /> Nature of Service Request- M ✓ l7 ✓e 4er"viee e6det <br /> Assigned to i _-- Employee Dater <br /> Date Service Completed: -Further Action 96CPA rdt <br /> PROGRAM ELEMENT �7- <br /> Fee Amount Amount Date of Payment payment Typo Retlelpt R .:- Chock I!` Reevd By <br /> un <br /> r f <br /> ACCT _/ / UNIT CLK <br /> • I • <br />