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SERViCt REQUEST (EN 00 61) Revised 8/23/93 <br /> FACILITY ID a . uCcmP IP 4 iN wu >y <br /> FACILITY NAME J �1�� EiLLIYG PARTY Y <br /> SITE ADDRESS <br /> CITY A 4047,�Y e�7 CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y <br /> /Q PHONE #1 ( ) <br /> ADDRESS PHONE 02 ( ) <br /> CITY STATE ZIP <br /> 1APN ar PLend Usa Application N <br /> 11 lI SOS Dist Location Code <br /> CONTRACTOR and/or <br /> ILLING PARTY <br /> SERVICE REQUESTORBY N <br /> / <br /> DBA A--- PHONE #I (2-rl) , <br /> MAILING ADDRESS /` y�� / � /"" FAX d ( ) <br /> CITY _/} /'I IiTATE�ZIP <br /> BILLING ACKNOWLEDGEMENT; I, the undereiWW QWner, Qparatgr Qr aagnt Qf ww, acknQwla06e that oLL site and/gr proloct specific <br /> PHS/END hourly charges associated with Chia facility gr activity will ke kill@d to the party jdamified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that 1 have prepared tbis eppli@@titin and that the ygrk t9 W RErfumed Hill kW OgW in Q& �k'jth all SAN <br /> JQAQUIN COUNTY Ordinance Codes " Stan4aj-4, state and Fed@ral lees• �EI` E D <br /> APPLICANT'S SIGNATURE : MAR 1 2 199$ <br /> ' `J I <br /> Title: Oat. : T AVNCUUtJ'TY <br /> --- - — -- - ;!Trl SERVICES <br /> HEALTH DIVISION <br /> AUTHORIZATION TO RELEASE INFQRVATIQpl; I.n 4f4itien tp the QtQ-Yin, abs, iiw0ria10, i, The gYnar, gperawr or agent Of em, Of <br /> the property Located at the Qbgvv site 4Wress h@r@hy authgriie the relesss of any and all results, gsetechnical date and/or <br /> envirorwntal/sits assessment[ i(,.fQrWa.09n tg SAN 49AQWIN QATY PLIC HEALTH SBRVIGES 6NViRQ VTU MMTH DIVIBiON as soon as <br /> It is available and at the Same tiwo it is RFQvid@d w Hl@ Ar w representative. <br /> Nature of Service Requasti pp // /� Service Codi .l a oZ <br /> Assigned to — Eliployee d b b` - Date <br /> Date Service Completed / / /.� Further Action Required: Y Pp4LiRAN ELEMENT d f <br /> Fee Amcwt ARwunt Paid Data of Payment Payeir►nt Type R@cslpt E Cb.acr d Recvd ay <br /> is b � - 31i q ✓ fg� <br /> RENS StPV TWIT CLX /�J <br />