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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> [FACILITY ID # 0,313 RECORD ID # r0 INVOICE # a35�j3 <br /> LIIZ <br /> FACILITY NAME 44R&O A11?/11W 4-/7y 040 M/ TCL�A ew BILLING PARTY Y / <br /> SITE ADDRESS //015) S /hi4/.✓ ST <br /> CITY 1W,4^1r4W- - CA ZIP <br /> RUSH <br /> OWNER/OPERATOR 47-4-Aw.,'7-J4:t ne�/ BILLING PARTY 1 6) / N <br /> DBA /4REL2 -1032 ,) Nal 7S GD/h }� PHONE #1 ( 714 )6-7v - sj c l <br /> ADDRESS 4CEN7E,2f�NTE � PHONE #2 ( ) <br /> CITY L14 pI>+ 4-1,q STATE � gg/7 ZIP [ 9&73' <br /> APN # IF Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR r/L i SEL�e�ED 14-r7/di< Tlit�lc BILLING PARTY Y ! Q <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 /> PNS/END 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. <br /> 1 also certify that 1 have prepared this application and that thelrll�- <br /> e r t e done ii accordance with all SAN <br /> x� <br /> JOAQUIN COUNTY Ordinance Codes and andards, State and Federal t JAN <br /> �� <br /> . J F11�1 <br /> APPLICANT'S SIGNATURE 6-7 <br /> 97 <br /> SAN JOAC,U11N -; J,_''" <br /> Title: �{/z� �Fi?M/T �I�ENT Date:, PUBLIC HEALTH SERVICES <br /> cNVIRONMENTAL HEALTH DIVISION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, 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 D b4jEmployee # "1 Q 3 Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment ype Receipt # Check # Recvd By <br /> EHSSUPV _/ / ACCT U�/ D I /` UNIT CLK <br /> (1 <br />