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f �y <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> [A�CILTY ID # &.7J 3 RECORD ID # d — INVOICE # <br /> FACILITY NAME 14Je60 !?M1,qY! ,, L,7y1�3/3 M/hJfcC�A G� BILLING PARTY Y / <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWNER/OPERATORArLi4d[T/L° 2/Lzt1F��Z–O IC�WI�O/{./� BILLING PARTY / Ej <br /> DBA 4AT,0 J822 z)bullT5i PHONE #1 ( 7/4 ) 7a S 7� <br /> ADDRESS 4 cC^11 A),wrE LIQ PHONE #2 ( ) <br /> CITY STATE ef-,4 ZIP 1073 <br /> APN # and Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR i-/(rj /J-r 7N,< 7-1eZ,- BILLING PARTY Y / 4 <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS FAX # ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge thAt all site and/or project specific <br /> PHS/EHD 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. ee.. NET. <br /> I also certify that I have prepared this application and that the work to be performed will be dofx��(M9rda ce with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and andards, State and Federal laws. OF " <br /> APPLICANT'S SIGNATURE JAN 311997 <br /> SAN JOAOUIN COUNTY., <br /> Title: AR-C,2 46--,v7— Date:_ iJRI IC HEATH SERVIf-ES <br /> ! NVIRONMENTAL HEALTH DIVISIO` <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of some, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment informaticn to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: Service Code <br /> Assigned to Employee # `>J R Date /-3 <br /> Date Service Completed -/-/ Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Ty Receipt # Check # Recvd By <br /> RENS / SUPV / / ACCT W w�/ e)C/ / UNIT CLK _/ / <br />