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SERVICE REQUEST (EH 00 bi) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # G� INVOICE # O <br /> �( � <br /> FACILITY NAME V\ 3 tIly1 /,��nr I ro'f \ es (nap BILRECEIVED NflYoY / N <br /> SITE ADDRESS S 5- I �oK^�-�-� " 'y` <br /> µ� <br /> F,t ��11 er•,�- <br /> CITY S+OC L< tq atA, CA ZIP 95207 <br /> SAN JOA.QL I!:•i tr„;NTV <br /> -c ^ - nPUBLIC0FALTHSr"r^i1;FS <br /> M Id <br /> OWNER/OPERATOR S SI )y 1 QTS_f..�Is{.-Les a� E BILLING PARTY �Y / N <br /> DBA PHONE #1 ( 20 1 )-Y7 L <br /> ADDRESS ,J S1 �M'tJ..G.1�V7lIl q PHONE #2 ( ) <br /> CITY S�o C 1-r STATE C1 °'t ZIP 15,20 7 <br /> ppN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR c V BILLING PARTY <br /> DBA .,, PHONE #1 (Z 11 <br /> MAILING ADDRESS 112,�140 C N-�t�( AV 4 FAX # ( 201 )-qf7 "a S � <br /> CITY r c K 0 STATE C ZIP 9 3 7 x ) <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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 and that the work to be performed will be done in act j(cMEENTall SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal Laws. RlErEIVE D <br /> APPLICANT'S SIGNATURE <br /> Title: <br /> S (�L' Date: J` 1/ 0 .. 5F SAN JOAQUIN COUN FY <br /> PIIHCTC HEALTH SERVICES <br /> ENVIRONMENTAL HE�(LT�I DIgJSION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent o s <br /> the property Located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <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 QRequesst: Service <br /> I , p Code <br /> Assigned to /f/t.��( #-'I� EapLoyee # Date <br /> Date S i Completed / / Further Action Required: Y / N PROGRAM ELEMENT 7i> <br /> e Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 0 <br /> SUPV /_/_ ACCT / I I / C' / UNIT CLK _/_/_ <br />