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SERVICE REQUEST (EN 00 61) Revised 8/23/93 <br /> FACILITYID # T y GC INVOICE it <br /> FACILITY NAME �O«TN /�hs i/' gifif41 12F ZEAS-.1 I 81LLING PARTY Y / <br /> SITE ADDRESS � ,4 C) MIDDLE 006_2 <br /> CITY / 2,4r-./ CA ZIP <br /> i <br /> OWNER/OPERATOR �/z• c7fi57 �C/V..(EN BILLING PARTY Y / 9) <br /> DBA i 1 ,j 1 ( I PHONE #1 ( S /D ) �(-���- OD �o <br /> ADDRESS � 24 2,y �iN�A �- .Y.VG I_ PHONE #2 ( ) <br /> / <br /> CITY `, AI/OAI C/7V STATE (A ZIP �/4 �' ! <br /> APN # Lard Use Application # <br /> F l" <br /> Q/ _ O BOS Dist Location Code <br /> CONTRACTOR and/or (A n /(U <br /> SERVICE REQUESTOR DoAj FBI <br /> LLING PARTY O/ / N <br /> OBA l�A�LE AC e:5LAPHONE #1 ( 7L ? 7%�-, <br /> MAILING ADDRESS U ELY 37 24 FAX # ( ) <br /> CITY L-OC4: STATE L ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of sante, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with sol SAN <br /> JOAQUIN COUNTY Ordinance Codest ds, St nd Federal Laws. <br /> PCs 1 <br /> Cs �] L <br /> APPLICANT'S SIGNATURE : V +Q <br /> J H <br /> Title- Date• AIF �(r o, <br /> Mq(6Z [t7- P16FS <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same;"nf_�_ <br /> the property Located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirorientOL/site assessment information to SAN JOAQUIN COUNTY PUBLIC WEALTH 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; Service Lode <br /> saw <br /> � p <br /> Assigned to IQA 0 A AA Employee # Q (\ Date -2— / <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT 2. C) <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd ey <br /> REBS -�0�' ACCT _/_/_ UNIT CLK <br />