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SERVICE RF0UF.S1 (ETI 00 61) Revised 8/23/93 <br /> ►AGILITY ID p 1,/ !1 I RECORD ID 0 I O/ I INVOICE U I 04/ 3/ <br /> FACILITY NAME �P�J'/Ul1L� W• Nell`//O�D F I>9/�/ C'%r�� r BILLING PARTY Y / <br /> SITE ADDRESS Z� yD1 �✓�/� I� `' <br /> clrr Cl�,�'J cn zip <br /> OVNFR/OPERATOR � h��_�i�' A!�dl —BILLING PARTY I —Y / <br /> ORA PHONE #1 ( ) <br /> ADDRESS <br /> PHONE N2 ( ) <br /> CITY STATE ZIP <br /> FAPN H ---- — —Land Use Application 0 ---� � �•7 / nos Dist Location Code <br /> CONTRACTOR mxl/or rf G p <br /> SERVICE RF00FSfOR �✓y/�/// � BILLING PARTY \Y ) / N <br /> ORA 1�T+y13�/J !>. // fI SG�✓yr s PHONE #1 <br /> MAILING ADDRESS IG ` l L/Z� �/' YY� s FAX H ( ) <br /> CITY Ape STATE � .— ZIP <br /> BILLING. ACKNOWLEDGEMENT: 1, the taxTersigned owner, operator or agent of some, acknowledge that all site and/or project specific <br /> PIIS/END hourly charges associated with this fncility or nctivity will be billed to the party identified ns the BILLING PARTY on <br /> Page 1 of this form- <br /> also/c6tify that I have prepared this application arxi that tine work to by performed will be done in accordance with nit SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. PAYMENT <br /> / � RECEIVED <br /> APPLICANTS SIGNATURE _tet-f/'7�L/JZ� ` . <br /> �, ✓i/ _ ,���.- Dnte:_ ✓5"9 BSEP 51997 <br /> �OMAL4N91pW16r'"V,I ne o f <br /> AlII11CNTI7A110N 10 RELEASE INTfAiMATIUN: in addition to the nlx)ve, when applicable, I, N)e owner, o LT pTVI lOr� <br /> the proFrrty Incnted at flip move site nddress hereby nuthorire flip release of any and nil re-;tJF IR(ON�4i�C t (Pnta orxi/or <br /> soon as <br /> envirornrntal/site assessment information to SAN JOAQUIN COUNTY PIIBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as <br /> It is available end at the sane till*- It is provided to me or my representative. <br /> Nature of Service Requpst: _ Service Code 7_ <br /> Assigned to Err<.)loyee 0 Date / —/ —7 <br /> Date Service Crnpleted / —1L_ Further Action Required: Y / �! PROGRAM ELEMENT Z <br /> Fee AmoOnt Amount Paid Date of Payment Payment Type Receipt N Check 0 Recvd By <br /> SUPV l -- / / --- ACCT I�b. 0q_1 08 /_L— I UNIT CLK <br />