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SERVICE REQUEST (SERVREO) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # 1 ! A A INVOICE # <br /> FACILITY NAME 0&,41 BILLING PARTY Y / N <br /> SITE ADDRESS (�fzQnLllbill� F.F� 2QS'� D'�� KQS58'�11p�ryPd <br /> CITY <br /> /�hhL{1\1 �.�}�CA ZIP '•""�-r-`- <br /> IMNFR/OPE.RATORyV I w 0 ��//��, I l \J b m d <br /> � dk BILLING PARTY L Y,./ N <br /> DBA '1 /� PHONE #1 ( ) <br /> ADDRESS aI L- IT J� Ls SC)Yl I PHONE #2 ( ) - <br /> CITY L' l_ STATE IA ZIP c,53 I�L ���� I <br /> APN # `� r� Land Use Applicatti�on # <br /> Z5 5- C ) — v� E S i� BOS Dist Location Code <br /> CONTRACTOR and/or X 1 <br /> SERVICE REQUESTOR _ I VP.rri��' /�'�.,l,� . n-ArAcr sa,nBILLING PARTY Y / N <br /> DBA ` V Y V( 11 c�L1Y1 �r� JQ`� G!'1C:> PHONE #1 ( -4tJ'-"1)cv <br /> z�(z�1- JG <br /> MAILING ADDRESS ZZ.11__ �4{UV-S'IL� L-�' y F1A�X 0 <� <br /> S ` <br /> CITY �,d� I STATE _ ZIP CZ 4Q <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PMS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page i of this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in scF&A"Wall SAN <br /> JOAOUIN COUNTY Ordinance Codes and Standards, <br /> ,SState <br /> �and Federal laws. RECFIVF n <br /> APPLICANT'S SIGNATURE : �� • / �--�_ AUG 10 1995 <br /> SAN JOAQUIN COUNTY <br /> Title: 1445T -OC-•T Date: N A PUBLIC HEALTH SERVICES <br /> ENTAL 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 available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: .'O- f Service Code <br /> Assigned to �}'t \ rZYtw 1.0 2 Employee # p Dale P / <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # It By <br /> I (t5 ,00 � <br /> RENS / / SUPV _/ / ACCT _/ / UNIT CLK _/ / <br />