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4 • SERVICE REQUEST <br /> • (EH 00 61) Revised 8/23/93 <br /> FACILITY IO # <br /> RECORD ID # t,e '- - INVOICE # 030 <br /> ' <br /> .^A)DCAL ss BILLING PARTY Y / N <br /> FACILITY NAME V '7 <br /> SITE ADDRESS 7303 PAIN/e NE qq <br /> CITY """ CA ZIP.. <br /> q )S /MS0e �l�i5 � �% 81LU NG PARTY Y / N <br /> OWNER/OPERATOR l-/' ijif � L�q� Q� <br /> PHONE #1 ( 7f q)-LLi"�" <br /> DBA / <br /> ADDRESS 13/5s�a PHONE #2 ( ) <br /> CITY 7�.yJxl /TN{� STATE 0I. ZIP 7a 70� <br /> �APN # �Land Use Apptication # I ( Location Code <br /> III BGS Dist <br /> CONTRACTOR and/or /lq BILLING PARTY Y / N <br /> SERVICE REOUESTOR �,2 Nn> <br /> PHONE #1 (J/ ) r23 " �O a <br /> DBA ,,// <br /> FAX # (711 <br /> MAILING ADDRESS � 97^ " "" � c� �7 <br /> CITY .S�Ji,T4 /4 STATE L� ZIP /a /D5/ <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 to the party identified as the BILLING PARTY on <br /> Page 1 of this form. PAYMENT <br /> RFC CIWr- 1 <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 /> JOAOUIN COUNTY Ordinance Lod end Standard State and Federal Laws. JUN 12 1996 <br /> SAN JGAOUIN COUNTY <br /> APPLICANT'S SIGNATURE <br /> cNVIRONMENTAL HEALTH DIVISION <br /> Title: 111a CWS SOC/A—MS' IA�& _ Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmentat/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION assoonas <br /> it is available and at the same time it is provided to me or my representative. <br /> service Code <br /> Nature of Service Request: y ' v" <br /> � <br /> Assigned to l7 <br /> N�%/J___/U lam. E�loyee # Date _/_J <br /> //. 41 <br /> L 4 <br /> Date Service Completed __Ll /M Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount AmountPaidDate of Payment'n Payment Type Receipt # Check # Recvd By <br /> i <br /> SUPV /_�__ ACCT �,J UNIT CLK <br /> I <br />