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SERVICE REQUEST (EN 00 613 Revised 8/23/93 <br /> FACILITY !D # RECORD Ib # INVOICE # a 3 7 33 3 <br /> f <br /> � T <br /> FACILITY NAME UD iS CATgA I-7 I SBILLING PARTY .Y" ./ N� <br /> SITE ADDRESS �33�� RFrzrGK - <br /> e1TY CA zip _ <br /> OWNER/OPERATOR BILGING PARTY / H <br /> DOA PHONE #1 f ) <br /> ADDRESS - _ PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN N Land Use Application # <br />. ,ten� � �� ��� � 905 Dist Location CodeIF, . <br /> - !'f - <br />' ==J <br /> CONTRACTORand/or <br /> F R 1i4ALr NT��Z NSPCC aN ��/ I �J <br /> BILLING PARTY 9 / <br /> SERVICE REG11E5 0 <br />' 1I <br /> DBA 1` t PHONE 61 <br />" MAILING ADDRESS R,/Q rr FAX # ( ) <br /> cltY dODELM <br /> STATE ZIP <br /> i <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, ocknowledge that SIP FaljteTand/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the partl Gfeyt fled as he BILLING PARTY on <br /> Page 1 of this form. SAiv31997 <br /> i �� <br /> L RO�aloq d Le s faccordance with all. SAN <br /> 1 also certify that 1 have prepared this application and that the work to be perfo {�y�L�� <br /> JOAOUIH COUNTY ordinance Codes Standards, a and Federal laws. N � TAL HEALTH DIV*, ._ - + <br /> APPLICANT'S SIGNATURE <br /> - / <br /> U -2 � <br /> Date: <br /> Title. - <br /> AUf110R12Ai10N TO RELEASE INFORMATION- In addition to the above, when opplicable, J,. the owner, operator or agent of same,, of <br /> technical data and/or <br /> the property located at the above site address hereby authorize the release of any and all results, Bea <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH 6IY1510N as soon as <br /> nm <br /> it is available and at the same time It is provided to me or my representative. j <br /> Service Code <br /> Nature of Service Request: <br /> I <br /> l Assigned to mployee # _ d_ Date <br /> —7 I <br /> 1 / Further Action Required: Y / PROGRAM ELEMENT. <br /> Date Service Completed i / / <br /> i <br /> Check # Recvd <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # 8Y <br /> r <br />