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SERVICE REQUEST (EH 00 61) Revised B/Z3/93 <br /> FACILITY ID # RECORD 10 # �A 7 9G 1NVOEGE ak <br /> FACILITY NAME f P BILLING PARTY Y <br /> SITE ADDRESS f <br /> CITY "� CA ZIP <br /> OWNER/OPERATOR "lC G 81LLlNG PARTY Y / N <br /> DBA 11 4 PHONE 91 ( :J ) .s <br /> ADDRESS TD 7 1 �~4 �a-*N ve PHONE #2 (i'0 1 ) �+J V. F�a- <br /> CITY f STATE CA ZIP 'I Y 2� <br /> APH # IF Land Use Application # - <br /> BOS Dist Location Code <br /> CONTRACTOR and/or J C` P'LL 4 O I V-l� Tt cw;C� PO's <br /> SERVICE REQUESTOR i ( `'\( V I �J BILLING PARTY �� / N <br /> Cl 1C `�1 �p ✓U � a�UVi PHONE #1 t � ) �"�' <br /> - DBA q <br /> MAILING ADDRESS �3 G 4 Ai J t,'1 Lkz FAX <br /> CITY Ivwi ; STATE ZIP [ -� <br /> BILLING ACKNOWLEDGEMENT: I, 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 Co 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 Standards, State and Federal laws. e4yMEN-( <br /> APPLICANT'S SIGNATURE <br /> /` <br /> Title: Date. f } � F.EB 5 X998 <br /> cr utiTV <br /> AUTHORIZATION TO RELEASE INFORMATION; in addition to the above, when a(ppLicagle, 1, the other, operator or agent'of"'spore, OT-t0t,; <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical date and/or <br /> environmental/site assessment information to SAN AQAALIIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIV15ION as soon as <br /> it is available and at the saw time it is provided to me ar my representative. <br /> Nature of Service Request: Ir r S-U Service code f`( <br /> v O f i6 y <br /> Assigned to Employee # _ Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT (f} <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt Check # Recvd By <br /> REHS �/ / �_S 5UPV / ACCT J /_ N6T CLK _/ / <br />