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SERVICE REQUEST 3 `j 7PAERVREG) Revlsed 8/23/03 <br />rAC.ILITY 10 R <br />I RECORD ID N <br />Date of Payment <br />INVOICE M <br />LJ <br />rACILITY MAHN <br />ADDRESS til �= 1z;,4111 r v <br />a1LLIN0 PARTY Y / N <br />rSmlrR/OPERAtOR VA n/ pZ9 BILLING PARTY YNN <br />�// -� <br />DRA 3507 �ILLV JRD• SURD. 3-&: FPNOIE 01 (�)JF�- Y9FyV <br />MDRESS 1/,YJ&2liES / y PHONE #2 t ) <br />CITY <br />STATE ZIP <br />MM R Lard ��'U���s111e���,,,Appll on cat ----- <br />F 5 _ !Z <br />—,%3 <br />BOS Dlet Location Code <br />CONTRACTOR and/or 117 1 <br />SERVICE REQUESTOR BILLING PARTY cy) / N <br />DBA ,�// �/� /� / !\7 PHONE 01 ( <br />MATLING ADDRESS 1 y�y/� �T/ `� �`-7�F /l�-KA Lf J�rAx 0 <br />CITY / - I00� FS/ C/ STATE � ZIP � �,/ / <br />RII.LING ACKNOWLEDGEMENT: 1, the underalgned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PIIS/Elm hourly charges easociated with this facility or activity will be billed to the party Identlfled as the BILLING PARTY on <br />Pnge 1 of this form. <br />I nlso certify that 1 have prepared this appllcatio and that the work to be performed will be done In accordance with all SAN <br />JOAQUIN COUNTY Ordinance codes a tardards, a / Federal laws. <br />APPLICANT'S SIGNATURE <br />i <br />1 A1114DRIZATION 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 sit renutts, geotechnical data arid/or <br />envirormental/site assessment Informatlon to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />It Is available and at the same time It In provided to me or my representative. <br />Nature of Service Request: I => <br />Assigned to e &,e 4A57?w Employee 0 DG ?- <br />Date Service Completed 12-7 /0�5/ Further Action Required! <br />Service Code '")aa: <br />Date / / <br />Y / N PROGRAM ELEMENT�— <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment type <br />Raceipt / <br />Check 0 <br />Recvd By <br />i5U,00 <br />l�.ev <br />tp-?f`6 q4 <br />CSL <br />fin <br />S _, /_ SUPV _/ /_ ACCT (�/ / UNII"CLK / / <br />