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tD&n "`�'�(1L ` SreU ��a✓� 12o -4,P714 <br /> SERVICE REQUEST COLO �(EN 00 6��6.tIS:tl 8/23/193 <br /> fA[I;.I TY IDN � ` y RECORD ID Y oo INVOICE N cxm o <br /> FACILITY NAME � 12 lC(f-,c0 ti ��� `f J2, _ BILLING PARTY Y /` N� <br /> SITE ADDRESS _ 13�Q� e •�g"fid <br /> CITY CA ZIP - <br /> 6 Is VA <br /> OWNER/OPERATOR �'_`- �" .../`•�'�^+ BILLING PARTY Y <br /> DBA / �/� PHONE 91 (__) <br /> ADDRESS 17 S`( G' <br /> S _ ✓V�G'�r-40.x' PHONE C, < ) <br /> CITY STATE ZIP <br /> pMN N Lard Use AppLiestion N <br /> I F BCs Dis[ Location Cook <br /> CONTRACTOR arid/ <br /> SERVICE REQESTo _ • � / <br /> BILLING PARTY / N <br /> DBA PHONE 91 ( ) <br /> NAILING ADDRESS Z21 Z//�r ( � L FAX N(_y(/ ) <br /> CITY STATE/ L 21P <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned Owner, operator or agent of same, sckro ledge that all site and/or project specific <br /> PRS/END hourly charges assoc isted with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page I of this form- PAYMENT <br /> pc/`r�••rn <br /> I also certify that 7 he p 's eppli tr and t the [o be peri ullL beck". in aeCerdartee with all SAM <br /> h L <br /> JOAQUIN COUNTY Ordi Codes St erd S 2'e and FeN al law . APR 2 3 1996 <br /> SAN JOAQUIN CO pN I <br /> APPLICANT'S SIGNATOR ` PMET- <br /> I PRI lr <br /> i Z 3tyYIRONMENTAL HEALTH DIVISION <br /> Title: Date- JJ�� <br /> AUTHORIZATION TO RELEASE INFOtNATIONI. 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 oil reaults, geotechnical data arid/or <br /> environmental/site assessment Inionastion to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soot as <br /> it is available and at the came time it is provided to me or m/ representative. <br /> Mature of Service Request: �1 nn Service Co* <br /> 1 �,� N v( V t t ( <br /> Assigned to Date <br /> Date Service Completed �/ / (�_ rth Action Required: Y /1 PROGRAM ELEMENT Z <br /> Fee WArit Amount Paid Date of Payment Payment Type Receipt N Check N Recta By <br /> i <br /> (/ 7 <br /> HS ACCT / /41V UNIT CLK _/_�_ <br />