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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # h �/f'1 /�� RECORD ID # /J /, n <br /> // _ /, 0 c e � r%� ��U�r <br /> FACILITY NAME <br /> —/ BILLING PARTY Y' / <br /> SITE ADDRESS > <br /> �D}' <br /> CITY SyV�-'I(+L CA ZIP <br /> OWNER/OPERATOR GUG^I1!-Ci97 LGA BILLING PARTY T/Y / N <br /> DBA / PHONE #1 ( �) )j - 76Z) Z_ <br /> ADDRESS / -//- /J l�� /�� �PPH�ONE #2 <br /> 0Zk <br /> CITY �. T" V C/ ZIP '��I <br /> STATE <br /> APN # Land Use Application <br /> F # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or 1 <br /> SERVICE REQUE STORIL /2I'l L2- BILLING PPAA,R�TY� Y / N <br /> DBA ^' - r�/1 PHONE #1 <br /> MAILING ADDRESS �LAny.N ��J C II�C� �y� FAX # (-72= /j - 74 <br /> _ <br /> CITY &n� �.P)(7Y(1J� STATE C-t ZIP S-7 <br /> "a®t` l <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that ar1lyl.[�I toar>d/Or,(ppo)ect specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identiTitLING PARTY on <br /> Page 1 of this form. SAIV <br /> J�7 <br /> ENV/01V C NeA�/N GOON <br /> also certify that I have prepared this application and that the work to be performed will be donm*N4(r,I' with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. T14D/V/g/pN <br /> APPLICANT'S SIGNATURE q ' <br /> title: Dote: # i.�l —� 7 <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 all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN CDUNTY 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: y G Service Codeo---3 <br /> Assigned to M V`" Employee # � Date « / _/ R-7 <br /> Date Service Completed _/—/— Further Action Required: Y / N PROGRAM ELEMENT L 30 <br /> Fee Amount Amount Paid Date of PaymentL Payment Type Receipt # Check # Recvd By <br /> v <br /> REIIS / 16t- SUPV _/__/_ ACCT L _/ UNIT CLK / <br /> 1 <br />