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SERVIC'c REQUEST (Eq 00 61) Revised 8/23/93 <br /> RECORD IO 4 � lINVOICE <br /> FACILITY IDyl,J i <br /> t 1 S�S� L� +� BILLING PARTY Y / N <br /> FACILITY NAME �� <br /> B1T'c ADDRESS <br /> �u��l l JQs� ToSo ke l�V2 — <br /> CITY M�,ak«-� CA ZIP ��3Z <br /> F=ILLING Y / O <br /> lNER/OPERATOR I�Cb�Q Sj^T---�— 1 <br /> PHONE 41 (r, ) �g ' to <br /> DBA J�'/� t <br /> i...000� _ PHONE #2 <br /> ADDRESS <br /> CITY , STATE S - ZIP <br /> ` '��-` T <br /> =A PN # p Land Use Applicatim # Bp5 Dist Location Code <br /> INTRACTOR and/or T C BILLING PARTY Y / N <br /> -RVICE REQUESTOR �L- --),)-'') <br /> PHONE 41 <br /> DBA 'I (�' � <br /> `oa� oto FAX # C 1o0 ) 4�0 - � <br /> lIL1NG ADDRESS � 4 <br /> Q STATE ZIP o <br /> CITY <br /> EDG'cMENT: [, the undersigned owner, operator or agent of so", acknowledge that alt alta and/or project specific <br /> 31LLING ACKNOwLActivitywill be billed to the party identtfiad ss the BILLING PARTY on <br /> IHS/EHD hourly charges associated with this facility or <br /> ?age 1 of this form. - „< a <br /> I also certify that I have prepared this application and that the work to 4e performed Nill be done {n aecordandi,�f th all SAN <br /> JOAOUIN COUNTY Ordinance Codd and Standards, State and Faderal laws F EB 1998 <br /> APPLICANT'S SIGNATURE <br /> Cate' <br /> Tltle-R' 2 <br /> pq <br /> AUTHORIZATION To EASE INFORMATION: In additon o wnop <br /> RELe <br /> rotor or agent of came, <br /> itthe Above, when VpLicabts, 1, the oer, <br /> the property Located REL at the shave site address hereby awthgrix@ the releass of any And all results, geotechnical dare srd/ <br /> s(,site COUNTY PUBLIC WEALTH SERVIDES Eµy{RDNIIENTAL WEALTH DlviiION as s <br /> environment asaessment information to SAN JOACKl1 <br /> it is avallable and at the $am ties it is provided to me or W representative. <br /> Service Code O <br /> Nature of Service 1R,OW66" <br /> (Me\� Employee r .2123 Date <br /> Assigned to eee� <br /> Date service Completed <br /> Further Action Required: T / N PROGRAM ELEMENT , <br /> Fee Amount AmounC Paid Oat@ of Payment payment Type Receipt # Chock # <br /> at <br /> UNIT CLK <br /> RENS <br /> 2 //fiC / SIMV <br /> a <br />