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1 <br /> SERVICE REQUEST CEN 00 61) Revised 8/23/93 <br /> FACILITY ID ! RECORD ID / 1 3 INVOICE * <br /> FACILITY NAME � uT �Kbp,Eri.�-y BILLING PARTY Y / <br /> SiTE ADDRESS3600 Gam(` 140LLUw <br /> CITY (I .y CA ZIP <br /> OWNER/OPERATOR bWA Aviv . &W BILLING PARTY / N <br /> Fc <br /> DBA A PHONE M1 <br /> :.s# ADDRESS qZ0 bWXP14AJ-1 kk . <br /> PHONE iQ (209� )��-b7� <br /> CITY ►"ib,ay'� STATE ""t ZIP <br /> APN S Land Use Application M <br /> BOS Dist Location Code <br /> CONTRACTOR and/or C ,^ <br /> SERVICE REOIESTOR 7C�W BILLING PARTY Y / <br /> DBA It PHONE !1 (?L)r? <br /> MAILING ADDRESS l Z.(7 �. !�� • FAX M ( <br /> CITY STATE uT' ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHD hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY an <br /> Page 1 of this form. <br /> 1 also certify that I have ad this spptication and that the work to be performed will be done in accordance with sit SAN <br /> JOAQUIN COUNTY Ordinance and Standards, State and Federal taws. PAYMENT <br /> �, RECEIVED <br /> APPLICANT'S SIGNATURE Wily Cp 1 <br /> Titte: hiAA, '� ,C�LtC,G Date: y- 12-97 SEP 1 5 <br /> 1997 <br /> SAM <br /> N.IQACN1 COUNTY`NITNIOItIZATION TO RELEASE INFORMATION: In addition to the above, whenrapplicable, I, the owner, of <br /> the'praperty located at the above site address hereby authorize the release of any and all results, geotM�l data or <br /> wartrormmmntat/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> s available and at the same time it is provided to me or my representative. <br /> 'faneiee Request: Service Code 0 C <br /> Employee M -t 03 ate / :► s ., 7 s': <br /> Further Action Required: Y / NPROGRAM ELEMENT <br /> timid Gate of Payment Payment Type Receipt M Check * Recvd By <br /> .ate=•- � <br /> ACC <br /> r UNIT'CLK _/_J <br />