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6-04-1998 1 : 26PI.1 FROM <br />SERVICE REQUEST <br />P. 2 <br />(EN 00 61) Revised 8/23/93 <br />FAC W TY ID p <br />1 %1 � 1} <br />RECORD ID # <br />'. DBA 1 y <br />TINVOICE k <br />I ___ - __= <br />FACILITY NAME Y�C�_L_) arl-_k:'Y \ l L..c._ • BILLING PARTY T / <br />SITE ADDRESS q >> I �� f - I�<-\ 1 (=_%ZLZ•U 1"�D- <br />CITY e5_1 C.X,1L IUYI CA ZIP `� `7 J U — <br />OWNER/DPERATOR <br />I- •1 .0 <br />BILLING PARTY Y / �N?j <br />'. DBA 1 y <br />l l <br />PHONE 91 <br />i- ADDRESS P O �`JCJi� <br />_ /_� <br />PHONE #2 ( ) - <br />CITY -,(�1� Q�LY1 <br />_C <br />n <br />STATE �_ ZIP 9,45ICS <br />� <br />PH B <br />and Use Application f1 <br />FOS Dist location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOOR��{�� <br />BILLINGPARRTYY <br />-AAAC-, PHONE 01 (I� <br />MAILING ADDRESS ta3� �. <br />, 1 t ' <br />J 1 Y G C./� FAX 1t () 1 _01H - <br />STATE CA ZIPq ) (� <br />C.T1 <br />(.A <br />j <br />K <br />' <br />BILLING ACKNOWLEDGEMENT; 1, the <br />undersigned owner, <br />operator or agent of Saab, acknowledge that all site and/or project specific <br />i'HS/EHD hourly charges associated with this facility <br />or activity will be billed to the party identified as the BILLING PARTY on <br />page 1 of this form. <br />P'W" 9= M7 <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance ��t6 (;F1 r" <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. JUN 9 1998 <br />APPLICANT'S SIGNATURE <br />- - SAN JOAQUIN COUNTY <br />PUBUC HEALTH SERVICES <br />Title: Date: (c' i �c� i /U ENVIRONMENTAL 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 information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is evaitoble and at the same time it is provided to one or my reprosentativc. <br />Nature of service Request: <br />Assigned t <br />Dote Service Completed <br />Service Code <br />Esployee *- Date <br />Further Action Required: T / N ! PROGRAM ELEMENT <br />fee Amount <br />TAmount Paid <br />Date of Payment <br />Payment Type Receipt M <br />Check B <br />Recvd By <br />UNIT CLK <br />_ /_� <br />supv <br />I <br />ACCT <br />^� �/ <br />UNIT CLK <br />_ /_� <br />