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SEitYICE REQUEST (EH dO 61 .Revfsed x/ 319$ <br /> ` FACiLITY Ib RECORD ID ii 1 <br /> titLi iNG PAR7Y.j'f �'- Y ,'t'/ N - <br /> FACILITY NAME [ M5? <br /> i <br /> SITE ADDRESS <br /> o <br /> CITY r <br /> CA (^ZIP <br /> Al <br /> OilNER/OPERATOR �CAD 4-8� /t't G G£E _ ' ` + BILLING PARTY.; T ''' /. N1 <br /> E DBA � � �.P}iONI: if1 ( � � + t���}c•�f <br /> h. <br /> (v5.3 t �>67TyIS�r c G» �L/� Gr PRONE 02 ( <br /> ADDRESS <br /> ' CITY �7—[ 6'e:7y STATE'" ZIP <br /> APN N Lend Use Application >y <br /> Bos bfat <br /> Location Cade 'qq� +,'^�•�., �' <br /> CONTRACTOR and/or <br /> M '.. Gk6 j #ILLING PARTY <br /> S ',' Y / N `!' <br /> SERVILE REDUESTOR ,JO +J 2 } •I <br /> r <br /> �bBA Qi4Lt L � HONE #1:(_)_?►v7 .r1 <br /> � k �r,i!� <br /> I�I�LTJ ' 4� FAk t! { ) � <br /> 46 ' NAILING ADDRESS <br /> s ' <br /> S t <br /> CITY s7A7E CAziP 53 „ af ' <br /> BILLING ACKN041LEDGEMEFIT: I, the undersioned owner; operator or agent of same, acknowledge that all 01:6�and/or projecf ipedfic� � I c <br /> PNS/END hourly charges associated with this.faCility or. iictirrity will be billed to the party'identifled as the BILLING PARTY,ond5: � �;„; <br /> Pee 1 of this form. <br /> 9 a' <br /> I also certify that I have preparedthis'applfcetibn ehd that the cork to be performed will be done in aceordarice with 1all SAW.rfTOW <br /> , : t z!, <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State end i ederal laws..' a�t <br /> APPLICANT'S SIGNATURE <br /> Title: - Date: <br /> '1., 'a .. � � i i .-^: .. !i� 5 f'' � ley t <br /> AUTHORIZATION TO RELEASE INFORMATION' In'addltton to the above, when applicable, I, the oWner; 'tiperator or agent of,same!, 0. <br /> the <br /> property located at the above site address hereby authorize the release of'eny aril all iresutts; geotechnical data and/or` .`;',yu <br /> envfrorxnentel/site assessment information to SAN JOACIUIN COUgTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH{ b11dfS14N as soon <br /> �. <br /> it is available aril at fhe same time it Is provided to tr� or my representative. <br /> fsSd� L 'SLt t7 IR.1 cfTU q Service Code <br /> } Nature of Service Request: <br /> � cc"ti <br /> iG p Ento ee4-109 i . -_- ` r�r <br /> }Assigned to <br /> LDate Service Completed / / Further Action RegUired:l., Y H PROGRAM ELEMENT!' d <br /> rh�� <br /> :�:W <br /> ` Fee AmoKmt Amount Paid Date of Payment' Payment Type . Receipt`s { Check # f Recvd 6y <br /> r <br /> RENS /0/ 931 SUPV / / ACCT UNIT <br />