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vtc� r7-972-9 <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> T` <br /> FACILITY ID $ -- .i:n, ..Ii RECORD ID # /) cY CJs INVOICEo <br /> # <br /> UC `t9 <br /> FACILITY NAME (`in ��YA&,MI Lf�' I 7(n C BILLING PARTY Y <br /> SITE ADDRESS �(?)1n \Va \HCl (,n)(1 kA� `,`C–(e'1_Q�ZZ <br /> CITY CA zip <br /> OWNER/OPERATOR '('l'[1�-e1 a BILLING PARTY 1:=Y: <br /> / N <br /> DBA PHONE #1 ( /0-7O) - �20 <br /> ADDRESS \ H/Vr� �Vl� PHONE #2 (Aoo)�_- 32 3 <br /> CITY L.1C\TV CA ('STATE �J-A ZIP9 <br /> �APN # p Land Se Application # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING PARTYY / N <br /> DBA n N - .LN PHONE #1 (91` ) n`T 5- 22 <br /> MAILING ADDRESS L L)' FAX # ( � 1 h) _12`x' <br /> CITY STATE 1A_ ZIP 9Sg15 <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 id rL�'fied as the BILLING PARTY on <br /> Page 1 of this form. IPC, r, �; <br /> ✓ /(*R'.. <br /> 1 also certify that I have prepared this application and that the work to be performe�,�ilL bb cpny�in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes #G"Standards, State and Federal taws. P,y �o�z'���q�r/hCJ�996+ <br /> APPLICANT'S SIGNATURE � <br /> Title: 6 ^(��\�Q✓V ate: n�7h(eal ken y�q`ry�ci>s <br /> /S/aN <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. c <br /> Nature of Service Request: pp Service Code ' -T X <br /> JZto �14-cJ�4 G1-. rrployee # Of Ct d3 Date -z-/4.�—/ <br /> Date Service Completed _/ / Further Action Required: Y / N [:ROGRA: ELEMENT 2 S <br /> Fee-7 <br /> Amou.ntt Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> � _/ L1 <br /> 3�4 Y G <br /> RENS /_ SUPV �/_/_ ACCT �/ / UNIT CLK _/ /_ <br />