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SERVICE REOUFST (EN 00r 61) Revised 8/23/43 <br /> ` FACILITY ID # I v fl� RECORD IDM I ( DINVOICE # <br /> FACILITY NAME 7199 76 BILLING PARTY Y / <br /> SITE ADDRESS L39 ilk I ✓ t4c-I A) ST, p�— <br /> C 1 T Y M A'/L.)T/.-err CA ZIP <br /> OWNER/OPERATOR -5 0 7W 1'9,U D CJee_P- BILLING PARTY 'Y <br /> DBA PHONE #1 <br /> ADDRESS a7// .Ui ,�f�sKCGG SJ`. PHONE #z (,L/D > �/�3'• // <br /> CITY STATE TX ZIP <br /> APN # and Use Application # <br /> ROS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REaUESTOR BILLING PARTY / N <br /> DBA Ski /li f PHONE #1 ( 2-1Y ) 374,+� 67.2a2,�, <br /> MAILING ADDRESS FAx M ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the Under goad-ewner, operator-or-agent-ot-some, acknowledge that all site end/or project specific <br /> PHS/EHD hourly charges associ wi/t_hnthis facility pr ac ivity will be bi led to the party identified as the BILLING PARTY on <br /> Page 1 of this form. 3/ � V <br /> D O 3 k' <br /> 11,07 v n° <br /> I also certify that 1 have re are is application and that the work to be per ormed will be 4 drone- in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. A Li 1, 1 <br /> APPLICANT'S SIGNATURE : /) _ SAN i0y <br /> PUBLIC HEAt.7.-I SEFiVICF:S ' <br /> Title: '5�-.)7— Date: A -- ;� ENTAL HEALTH DIVISION <br /> AUTIJOR17ATION 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 information 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 �� "" q ,Employee # Date —Y—/ / t b <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT _ O3 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS C�7 /2 L SUPV _/ / I ACCT _/ _/_ _ UNIT CLK <br />