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s w§� <br /> SERIFICE REQUEST (EH 00 61) Revised 8/23/93 <br /> PACiLiTY ID # RECORD ID # I INVOICE # <br /> o <br /> .. ��tCit9FY� NAME "T6 "n STN e-0 �NT BILLING PARTY <br /> t.Zv� ,),SITEY / N <br /> $eaVST NtD p i< b F ��czo rte] p e s�ADDRESS ' Ell- dF r—ORP—�l_. R-o LL1OL� <br /> °: <br /> t �y' CITYCA ZIP. <br /> UWNER/OPERATOR DPS r y F-i PA O N I E Z 0S S S BILLING PARTY Y / N <br /> ra*'- <br /> DBA VANO Ca►JS-CY2t,L�T1 rJ `SNC 9 <br /> PHONE #1 ( �0 1 > 577 - <br /> ADDRESS X ! 1 PHONE #2 ( Zl7 , ) 5 3 3') <br />,hart CITY E-STtZD STATE ZIP <br /> t,^y, APR # land Use Application # <br /> 0(4C) — C)2— LROS Dist Location Code <br />',„;_DOi1THACTOR and/or <br /> Z... <br />-,�'� ERVICE REQUEST09 BILLING PARTY Y / N <br /> DBA PHONE #1 (aoet _=7 3 ,13 O <br /> s,lAIUNG ADDRESS10 <br /> FAX #Pff <br /> CITY STATE ZIP <br /> „KILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific <br /> <-,;4HS/EHD haurly 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 /> also certify that I have epared this a plicati n and that the work te be performed will be done in accordance with all SAN <br />'.�j ibAwIN COUNTY Ordinance C and Stan s, and Federal laws. <br /> i APPLICANT'S SIGNATURE <br /> Date: <br /> IITNoRIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> y•'the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> R"`I'environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> fit is available and at the same time it is provided to me or my representative. <br /> Nature of Service Requests hicdeZe Service Code i <br /> i <br /> Assigned to Employee # Date <br /> RSI 7 D Q C� I <br /> bate Service Completed / Lam( / ! � Further Action Require: Y / PROGRAM ELEMENT � 1 <br /> fee Amount Amount .Paid Date of Payment Payment Ty Receipt fr1 y.. ym ym t # Check # Recvd By p <br /> SUPV / f ACCT / 1 UNIT CLK <br />