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0 SERVICE REQUEST 0 (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # u O-n I INVOICE # %a 37777 <br /> FACILITY NAME /77 l BILLING PARTY Y / N <br /> SITE ADDRESS /t/• q <br /> CITY //' CA ZIP <br /> /�-G <br /> OWNER/OPERATOR �J�� ! '—�A „ BILLING PARTY Y / N <br /> DBA ri/�/ PHONE #1 <br /> ADDRESS �D f (/ AL(7 /J/"�(/Pg� /// G�(7PHONE #2 ( ) <br /> CITY (STATE ZIP <br /> P APN # Land Use Application # <br /> I � BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTO BILLING PARTY Y / N <br /> DBA PHONE #1 ( L <br /> MAILING ADDRESS �J%cZJ :-5 Pi/^ /FAX # (1`l�I <br /> CITY �� STATE ZIP �/ <br /> BILLING ACKNOWLEDGEMENT: 1, 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. <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 /> JOAQUIN COUNTY Ordinance Codes and Standar a Federal laws. <br /> APPLICANT'S/S//SIGNATURLE t 1 A /})y �1 zz� <br /> Title: (_X�iYI //LC�3 . ig"/�/J� Thr`(/. li, 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 alt 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 Request: 7'�katll ice Code <br /> Assigned to Employee # �DV Date / /? <br /> Date Service Completed / / V Further Action Required: / N PROGRAM ELEMENT J i <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ►o-a�-� , <br /> RENS /0 /-!3—/5L5- 1 SUPV / /_ ACCT ID/ 3 UNIT CLK _/_/_ <br />