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x;e <br /> CEN 0� <br /> �" fJ4l�'Revd sed 8123/9 Y, <br /> T i !� @RVICE itEOUESt.: <br /> F CLITY ID '' X JtECORD lDP E��DM- <br /> r"INVOICE # ` y <br /> f <br /> J <br /> FACILITY NAME ENITG PARTY Y ! N <br /> RqE VE I <br /> SITE ADDRESS r 195 <br /> lilt <br /> k G� 2iP UIN <br /> ' CITY COUN 31A <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTA <br /> BILLING PARTY Y / N <br /> ER/OPERATOR <br /> DBA PHONE #1 -75 <br /> ) - <br /> 'RHONE ) <br /> . ADDRESS V <br /> r CITY _ STATE VAP I ZIP <br /> APN # Land Use Application # <br /> BOS Dist ` Location Code <br /> L8ifgACTOR end/or t <br /> 3'EM CE REQUEST 7 BILLING PARTY Y N <br /> F <br /> PHONE <br /> FAX <br /> ILING ADDRESS <br /> CITY STATE ZIP �� <br /> LLNILLING ACKNOWLEDGEMENT: i, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific `. <br /> ty will be billed to the Party Jdentified as the BILLING PARTY on <br /> QHS/EHD hourly charges associated with this facility or'activi d- <br /> Page 1 of this #orm. , <br /> PAYMEN r <br /> I"also certify that I have Pr red this i Cionni that the work to be performed will be do with all SAN 4. <br /> ',(UdQUIN COUNTY ordinance Cad Stand ederal laws. . `1J�,` Y n 1995 <br /> F+ .t <br /> �PLICANTIS SIGNATURE t <br /> �'-. -, •F•Yi , Y,;., x ;' - 6866 HEALTH SERVICES - - • <br /> F . 1-1 <br /> 12: ` <br /> Date: <br /> EALTH QIVISION <br /> ' <br /> a „�,., <br /> to :�: 3: i. <br /> AUTHORIZATION TO RELEASE INFORMATION. In addition to the above, when applicable; if`the'ouner+ 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 COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> ,ii is avaitable and at the same time it i§ provided to me or my representative;} <br /> kf: <br /> '.Nature of SeN'ce RequesteService Cod *'e' D�b 0I <br /> rAssigned to Errployee # ' Datef <br /> r 4 :, <br /> Date §ervice Completed / ! Further Action RegUfred: S.Y / N rp <br /> ROGR�IY ELEMENT <br /> `,:Fee Amount Amount Paid Date of Payment ",'^: Payment ? ReceiptA#'" Check # Recvd By <br /> l <br /> 0- Z11 <br /> ,• ACC UNIT CLK J!_J <br /> ,u REHS Tom/ SUPV �/ f <br />