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use <br /> . SERVICE REQUEST (EH 00 61) Revised 18/23/93 <br /> FACILITY ID # <br /> INVOICE <br /> RECORD ID # � ' (�. l/[..y-�J-' r <br /> � � 1 BILLING PRRTY Y /� <br /> FACILITY NAME y \ <br /> SITE ADDRESS <br /> CITY ( CA zip <br /> OWNER/OPERATOR T�t�C v ` BILLING PARTY Y / <br /> `` '' PHONE #1 ( ) L C <br /> DBA ILKT"t— - <br /> ADDRESS �C�L Q� ( J) '�" PHONE #2 0 05 '/87- 17"15 <br /> CITY \ I� �- �- STATE Cd`'� . ZIP ��7 - fes <br /> APN # F Land Use Application # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or ^ BILLING PARTY / N <br /> SERVICE REQUESTOR 100 ut c- <br /> PHONE #1 <br /> DBA <br /> c � FAX # <br /> MAILING ADDRESS FA <br /> CTS { C� .«-�0. / X <br /> CITY Y n YIA C L STATE + . ZIP q 1 (' <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 /> I also certify that 1 have prepared this application and that the work to be performed will be done in accorrdancle with all SAN <br /> JOAQUIN COUNTY 0 divan Codes and Sta�ards, State and Federal laws. DEC 111997 <br /> 1997 <br /> SAN JOA <br /> APPLICANT'S SIGNATURE HEALTH SERVICES <br /> ENVIRONMENTAL HF DIVISION <br /> Date- / A <br /> „- 9 7 �, <br /> Title: � � K-.../-� o �--I �TT <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 date 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 tine it is provided to me or m/ representative. <br /> V7 Service Code n 3 4- <br /> Nature of Service Request: ,{y, ( �y <br /> Assigned to nEmployee # `t l� Date -LL/-AA-/-9-") <br /> t <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount �- ount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS %�z/� SUPV _ _/_ ACCT / UNIT CLK _/_/_ <br />