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,rn s Ct 3 10 V <br /> SERVICE REQUEST "'' (EM 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # Lo 4 111 I INVOICE # D-�/ 6 <br /> FACILITY NAME -r/him [ �.5,7�/y_yf Ljp7l'Z BILLING PARTY Y /Q <br /> SITE ADDRESS '7G'TJ /� • Lam/ <�!ls�YiL'./�� ��� - J/!./ <br /> CITY CA ZIP O �� <br /> op <br /> OWNER/OPERATOR �YI7Je / L�� /'J✓J'-liC�i"dJ�c.-- BILLING PARTY Y / <br /> DBA PHONE 01 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> IAPN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or7� <br /> SERVICE REOUEST0R.G/1A/L}j/7 �, �r_s��i — G J✓/� FI "/ • BILLING PARTY Y / N <br /> DBA " n / PHONE #1 ( ) <br /> MAILING ADDRESS ��Z'/ `7/0 �"hJJiC/G //Yo��I ti FAX # ( ) <br /> CITY —SC>�Y75 i'/ STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EMD 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 /> I also certify that I have prepared this application and that the work to be performed will be done irPAXAMM with all SAN <br /> JOAQUIN COUNTY Ordinance CodesawStandards, State and Federal laws. RECEIVED <br /> APPLICANT'S SIGA /✓r-z- ` UN N G 1795 <br /> Z, <br /> _ SqN J QUIN COUNTY <br /> Title: /_ // �h<�/J�t'�' Date: -A, n e z z. .P9 1EAI 7H SERVICES <br /> CN RONMENTAL HEALTH DIVISION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, o <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 JOAOUIN CCUNTY 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 /> , <br /> Nature of Service R( (( <br /> e��queess7t: �� Service Code <br /> Assigned to S}�-K•1� \, {7 Employee # J�Y Y-� Date / `L.2/ c� <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z_SyZZ <br /> fee Amount (Amount Paaiid(\ (Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS _/_/_ SUPV _/ /_ A /�,z/5 UNIT CLK _/_f_ <br />