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SERVICE REQUEST (EH 00 611 Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE <br /> FACILITY NAME �ln4P��\(' I �£(�, BILLING PARTY Y / N <br /> SITE ADDRESS 7.� _R� ►I'`�t .� _L�` � <br /> CITY ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / <br /> DBA ��F1 �� ,� _ PHONE #1 <br /> ADDRESS PHONE #2 <br /> CITY )q Lu STATE Cf�r ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR VV H F e7Kt O rZ64 M )�(-rn L C/^CW U LT-p0,j ty BILLING PARTY C) / N <br /> DBA tp / PHONE #1 <br /> MAILING ADDRESS 7 � D)C IO� FAX # <br /> CITY /v l O D 6S 7_,�) STATE �--7g ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all i ry project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identi t�2�BILLING PARTY on <br /> 174 <br /> Page 1 of this form. Y <br /> J U L 14 1995 <br /> 1 also certify that I have prepared this application and that the work to be performed will bes�o�e)inA actor ante with all SAN <br /> s, <br /> JOAQUIN COUNTY Ordinance Codeand Standards, S ate and Federal laws. PUBLIC 0 u�w <br /> TH SERVICES <br /> ENVIRONMENTAL LHEA HEALTH DIVjs�( <br /> APPLICANT'S SIGNATURE /�iL <br /> Title: l �i�G SI DE42— 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 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 /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: C 0L�;,U, (-}- (J-Vit,&\ Service Code ` , <br /> Assigned to (,AjEmployee # �� Date <br /> Date Service Completed / _/ Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ZY <br /> 1 1 ✓ 76,53 Ila S 3 � . <br /> RENS _/ / SUPV / / ACCT / /jaf� UNIT CLK _/ / <br />