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.� SERVICE REQUEST • CEN 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME �T1r,T ��12i1) ✓�S J--IJ C BILLING PARTY Y / N <br /> SITE ADDRESS <br /> CITY M�,ak«0. CA ZIP <br /> JNER/OPERATOR ��j- �1rQ �v\ch2� �fJ C- _ _ _ BILLING PARTY Y <br /> DBA PHONE #1 (5G ID IS <br /> ADDRESS ��>601\ CD) \`'nK0,r) Ld Y—ooC`J q PHONE #2 ( ) <br /> CITY ` '�fT 1�Q 1-� STATE A_ ZIP -IM 11--CDOL)% \ <br /> —APN # p Land Use Application # <br /> BGS Dist Location Code <br /> )NTRACTOR and/or <br /> 'RYICE REQUESTOR Cbz ��G BILLING PA,,R��T--Y�� ,'/'' Y /q N <br /> DBA C PHONE #1 (,��)(�- 1�1 5 4 <br /> AILING ADDRESS ?.,oUO aQpLocA�+. ✓�I�� �(.O*lam Q[} �CFAX # (, _)190 <br /> CITY \I �.c c.J.`�Q STATE 0.d'\ ZIP F1WU� <br /> 3tLLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all sit* and/or project specific <br /> QHS/END hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> ?age 1 of this form. <br /> I also certify that 1 have prepared this application and that the work to qe performed will be done In accordant* with ail SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Fadoral laws._. <br /> APPLICANT'S SIGNATURE <br /> at;:A - Pow- <br /> ALIT HORIZATIO <br /> UTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of sane, of <br /> the property locat*d at the above site address hereby AwthQrize the release of any and all results, g*otechnical data atd/or <br /> environmental/sits assessment information to SAN JOADUIN COUNTY PUBLIC WEALTH SERVICES ENVIROMMEYTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided t0 me or my represantative. <br /> Nature of Service Requests Service Code <br /> Assigned to Employee # _ Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROWIAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Racvd By <br /> REHS /_„_,�/mss SUPV _J_J^ ACOT ,,,��__ UNIT CLK <br />