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SERVICE REQUEST CEH 00 61) Revised 8/23/93 <br /> FACILITY ID # / L�,/ RECORD ID # � � S y a h INVOICE # <br /> FACILITY NAME ac4q- s BILLING PAR1Y Y / N <br /> SITE ADDRESS 23073 Se Ir C-J,-S Rd- <br /> CITY RtPO A--' CA ZIP <br /> OWNER/OPERATOR F0 aIz S &4. OJ-) C + ieaAm 1 BILLING PARTY Y <br /> DBA FOUR-Q 13og CO PHONE #1 ( ) <br /> ADDRESSs �C9 73 S �f[• �rLC.E--�' '17 �+ PHONE #2 ( ) <br /> CITY IL\(20 N STATE _�.A ZIP <br /> �APN # FLand Use Application # <br /> FRO—" <br /> ist location Code �./�' <br /> Q <br /> CONTRACTOR and/or n <br /> SERVICE REQUESTOR C" r\0.f I GS y-.J(�D ft-'A,'Z,.-,e-" BILLING PARTY / N <br /> ^� 1w <br /> DBA +Jj5C0V NT/ � `"""^-(o lnr� PHONE #1 (_00 9 )1ZCe- 06?4 <br /> MAILING ADDRESS I�{; r e /_0CA(5 FAX <br /> CITY MRSV i Z Com- STATE &4- ZIP T.�33 4C <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this f "<. to the party identified as the BILLING PARTY on .T <br /> cA <br /> Page 1 of this form. Q 15 --� <br /> I also certify that I have prepared this appl formed will be done in accordance with all SAN - � <br /> JOAQUIN COUNTY Ordinance Codes aro S d <br /> PAYMENT <br /> APPLICANT'S SIGNATURE rXECEIVED <br /> Title: APR 2 g'USI11998TT;(� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addi 1, the owner, operator ;LTFI k0* VICES <br /> the property located at the above site address y and all results, geatea11L1it*Nlda.PaEatWdi tVISION <br /> environmental/site assessment information to 5 VICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is pro <br /> Nature of Service Request: Service Code 1 F <br /> p� <br /> Assigned to \ Employee # \-/ C) C ' Date /ao _/ 2� <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid <br /> Date of Payment Payment Type Receipt # i Check # Recvd By <br /> -79 <br /> Vv <br /> 1 ` <br /> RENS C / / Z V SUPV / / ACCT _/ / UNIT CLK <br />