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r... F'. Z <br /> SERVICE REQUEST (EN 00 61) Revised 8/23/93 <br /> F- <br /> I FALILI TT ID # //� -F'� RECORD ID # 71777INVOICE <br /> FACILITY MAKELE_I ELI�i L, �j l L/6 --W NaU5_ BILLING PARTY T / M ) <br /> S I TE ADDRESS ha ii?�1D LAMB <br /> MB l—I b(I-E—: <br /> CITY _ L� ITL�© � Tt�1� G zlv► � , J✓�(1J <br /> WNER/OPERATOR �� - y�C 7' �i1IMT�y�rlll�y --1A 1 I I NANj BILLING PARTY Y N <br /> DF I VSCD GB�PC) t l� <br /> DBA �--r- [� /'� PHONE #1 <br /> ADDRESS /20 L _V I n I\� `, I Z 9 ac) /�— PHONE #2 (2D�) 4Ka -�O <br /> CITY c� /r1}-]'ll STATE , UA ZIP 9("% [0 I <br /> i�APB # Lard Use Application # <br /> IE <br /> BOS Dist Location code <br /> CONTRACTOR and/or r----- ,,//�� � /� 1 /�, --rye . <br /> SERVICE REDUESTAI I Rt VrIN l A �. NU ' JI�� �I / _-: BILLING PARTY Y / Y <br /> DBA PHONE #1 I6 <br /> Q,'� 1 <br /> DDR <br /> !WILING AESS FC^K� FAX # <yJy(�7) 40 Q99 <br /> CITY .l )t 1A �aeiA _ STATE �� ZIP `Y' �� .• <br /> BILLING ACKNOWLEDGEMENT: I, the Undersigned owner, operator or agent of same, eckWwledge that all site and/or project specific - <br /> PMS/END 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 I have prepared t ra application and that the wort to be pe�iolmed will be done in accordance with ail SAN <br /> J04WIN COUNTY Ordi Hence Cod d ander s, State d F! at la ' <br /> i <br /> APPLICANT'S SIGNATURE T i - - <br /> �iN��2oaijyln/7l— FEB <br /> Title: �l� IpY. . Date.. <br /> �N JOAQU� 7IN�COUNTY <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operataF�J p� 77 by} <br /> the property located at the above site address hereby authorize the release of any and all results, Rao Ce �.a�FYleie o'll/N <br /> e iromental/site assessment information to SAN JOAWIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to no or my representative. <br /> c <br /> Nature of Service Request: A,1` Servj ee Code <br /> Assigned toLIL Q21aployee k Yp -7 -3 h Date ;c_ / / 7 <br /> Date Service Caipleted / Further Action Required: Y / N PROGRAM ELEMENT -U c C <br /> Fee gmount Amount Paid Dace of Payment Payment Type Receipt # Check # Recvd By <br /> 10* <br /> REXS C!J / 7 / / 4 SUPV / / ACCT / /- .UNIT CLK <br /> 0 U� v u <br />