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• SERVICE REC)UEST C",O (.(SERVREO) Revised 8/23/93 <br /> TACILITY ID N-�n. .- 1` ,`,; RECORD ID M/1 INVOICE M /'� <br /> rACILItY NAME !�r/✓Y�- �IUA� l �(.J 1`i Lift I( e61 e- BILLING PARTY Y / `N / <br /> SITE ADDRESS -� IIf,*�iC jGC �(,(✓ <br /> CITY �1 "��i U ® ZIP <br /> nwNFR/nrFRATOR ^/0001P`.J�)/.0 Af-', BILLING PrAARRITYYJ Y <br /> DRA A- /� //_-11 ,�Qf',F (lE PHONE Mi (CXIA( ) u JV-CJS <br /> ADDRESS � �/- (2,Af // L/c n PHONE #2 (T) <br /> CITY STATE �A' ZIP %S�y <br /> ArN s Lard Use Applicati <br /> p <br /> I — DOS Dist Location Code <br /> 11 <br /> CONTPACTOR mid/or <br /> SrpvfcE REGUESTOR ��'�� S BILLING___PARTY <br /> DRA / l.-/ Q� /� PHONE 01 O <br /> MAILING ADDRESS � 03 C ��'�"L Y-�[J FAK <br /> CITY �i>� "S/l./V STATE C=-� ZIP f '761 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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 /> 1 also certify that I have prepared this application and that the work to be performed will be done In accordance with all SAN <br /> JOAGUIN COUNTY Ordinance Codes and Stardards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and ell results, geotechnical data and/or <br /> environmental/site assessment Information to SAN JGAGUIN 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: ��--S�G (�7r�-�GG� Ji/¢yNY _y,) ervice Code 0 <br /> Assigned to ��� (//USC%T Enployee Date <br /> Date Service Coapleted _1_4_ Further Action Required: Y / N PROGRAM ELEMENT � o <br /> Fee Amasnt Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> rW <br /> y <br /> RFHS _/ / SUPV _/ /_ ACCT _ /�/_ UNIT CLK <br /> Zr"� <br />