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1 �t f ' •fit , <br /> SERVICE REQUEST (EN t)(1 dl) Revised B/23193 <br /> .. RECORD ID M O/ y 3 Y �` INVOICE M <br /> fACILIIT ID K <br /> .c1L1Tr NAHE <br /> eIILINo PARTr / <br /> SITE ADDRESS ' yx as. T \Q f e W a <br /> t s `1.; <br /> CITYDMR/OPERATOR ` I Q /l`�N ra zIP <br /> , <br /> DBA PHONE K1 ( ) <br /> :-a PHONE 012 ( ) <br /> ADDRESS <br /> R) 4, STATE ZIP <br /> CITY <br /> APM N Land Use Application / <br /> Bos ol.c Loc.clon cods <br /> oc <br /> CONTRACTOR and/or,,: sr'. -t . <br /> BILLING PARTY <br /> 5ERVICE REQLESTOR <br /> DBA /p�L- 1 �D PHONE M1 <br /> MAILING ADDRESS D' �,O IDD tA.X 0 <br /> Cllr STATE 11P <br /> the undor►ipne <br /> ®ILLING ACKNOdIEDGEMENTix 1. d oa "rotor rator or agent of 60010, acknowledge that all sits and/or proJect apeclflc <br /> PHS/END hourly charges seem lsted with thle focilltr Pr OctivltY will billed to the party identlf n � BILLING PANTY on <br /> Page 1 of this form, Recjs/v T <br /> also certify that I h,v prepared this application and that the work to be pe rforxled w111 be c}y�_In acco•trd with all SAN <br /> "JOAQu1N COUNTY Ordinance Codes and standards, $tete Feder/al laws. UU �� ,997 <br /> AA EN F'lrJI�CJO'ApU/N <br /> APPLICANT'S SIGNATURE i i <br /> J ' INV 4L NVICL <br /> EALr"DIVIS,pN <br /> Titley Datet <br /> AUTHORIZATION TO RELEAS9'INFORMATION; In addition to the Above, when applicable, 1, the owner, oim rotor or opent of sm,e, Of <br /> the property located at the ave pit* address hsreby outhoriie the release of any and Oil results, geotechnical deco and/or <br /> bo <br /> www rorYlental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is available and at the ,ams tilm It Is provided to ore or we representative. (� <br /> service Gode 7 <br /> Mature of Service Re"stT•- _-- <br /> AseltMadtQ , 12' 6t�4 t/1/ L, E'rt'loyee r <br /> Data 2— <br /> ,:_. <br /> Further Action Required: r / N PROGRAM ELEMENT <br /> Date Service Completed <br /> Dat* of PaymenFry Amount Amount Paid <br /> t Pnyarent Type Receipt N Check r R"vd By <br /> UNIT Cl- <br /> TUPV :,�✓ ACCT <br />