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SERVICE REQUEST ../ (SCRVREO) Revlsed 8/23/93 <br /> rACILITY ID N RECORD ID N INVOICE N <br /> rACILITY NAME /1�/C �D-�� �=G��f�I�J'���� GILLINO PARI <br /> SITE IIDDRESS._r:7,--��/ ` / y'" E�s'N C�.Jog, n }y <br /> CITY _ �'�Y f�J P/f�L�fj�� CA ZIP ✓ �a�/ AID # <br /> 7i; � osS <br /> 0WHFR/0PERATOR �P� �/ls �d,6F�✓ BILLING PARTY T / N <br /> DRA ✓y!/ /,� l�i�JFiY"� f�if PHONE N) clz�w ) �Q � <br /> ADDRESST✓� /,, // A�� n PHONE 02 ( ) <br /> CITY �.��o� Uj C 7 STATE 21P 4-- py <br /> APN N In Use Applicatlon N <br /> Bog Dist Location Code <br /> CONTRACTOR nrd/or ' <br /> SFRVICE REGUESTdl (� �� 1` /.�/ �z�c,�y�J-(lJ����/E✓7iP BILLING PARTT Y / N <br /> DBA .!/ ✓ v / s/tS• -C%/�/ PHONE NI (�L-,- - �, <br /> MAILING ADDRESS /�GP/fC�� TAX N ( ) <br /> CITY oCll STATE ZIP <br /> BILLING ACKNOWLEDGEMENT! 1, the undersigned owner, operator or agent of some, acknowledge that sit alta and/or project specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> Pnqe I of this form. <br /> 1 nlso certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date- �•� 7�/ <br /> AIIl HOR1ZATION TO RELEASE INFORMATION! In addition to the above, when applicable, I, the owner, operator or spent of same, of <br /> the property located at the above site address hereby authorize the releane 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 some time It Is provided to me or my representative. <br /> Nature of Service Request! e4--le fi- �� � wlJ Service Code <br /> Assigned tof�le' Employee N Date —/—/ <br /> Date Service Completed / / Further Action Required! Y / N PROGRAM ELEMENT-��d—t' <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check N Recvd By <br /> RENS _/ /_ SUPV _/ /_ ACCT U/, UNIT CLK _/ /_ <br />