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SERVICE REQUEST • (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # r�l RECORD ID # I INVOICE # <br /> l/ �(flif <br /> LQ <br /> jam ���Cl BILLING PARTY,. <br /> FACILITY NAME i G.��N a (lam p ' <br /> SITE ADDRESS "( -I � �V � lRECV-fFr. <br /> 11n MAY - 6 1997 <br /> CITY y' ` 'f"�"' co' CA 21P `�I <br /> SAKI JCIAUUIIV CUU,I , <br /> I_C[ES <br /> OWNER/OPERATOR l 1► �LYYm�'� �UNIA `lP/l&TJT�ii iiE LII V1 SN <br /> (v <br /> 7 f <br /> PHONE #1 ( I`i )C ,�•� <br /> DBA 1ADDRESS .�OA L V� �1 PHONE #2 <br /> CITY �A,'�'l lJ'�"( STATE � ZIP <br /> APN # -'— Land Use Application !I <br /> SOS Dist L <br /> Location Code <br /> CONTRACTOR and/or <br /> BILLING PARTY Y / N <br /> SERVICE REQUESTOR <br /> PHONE #1 <br /> DBA <br /> FAX # ( ) <br /> MAILING ADDRESS <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, 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 inl1cS9f ?;uith all SAN <br /> JOAQUIN COUNTY Ordinance Codes and StaDdalds, State and Federal laws. +' `7; <br /> APPLICANT'S SIGNATURE <br /> Date: !• r;NN '�fa �u ll'J I ,._, <br /> Title: - _ <br /> UBL, hE �T tiF V'w c: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the oGA i,F'1Gplgb'e`ttorlor`#g0mf-IoCaaftl;;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 /> Service Code <br /> Nature of Service Request: �1 <br /> Assigned to • I' Employee # �J 7`�, Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT .n <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ACCT �/ /_/ UNIT CLK _/__/— <br />