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SERVICE REQUEST (Eli 00 61) Revised 8/23/93 <br /> FACILITY ID # - RECORD ID� #INVOICE 1t <br /> FACILITY [TAME f1 I,I YJI� \i� _ __— BILLING PARTY Y / <br /> SITE ADDRESS ���C) <br /> CITY ��� �--- -- CA z '--- —---- <br /> OWNER/OPERATOR --- &A YfiJ �I — 31LL1VG PAR'Y ---- ( / - <br /> DSl, l� I'1�us =-m ------ — PHONE #1 ( _) <br /> ADDRESS 1 r I ca- j----_- P'IONE #2 ( ) <br /> CITY �C (/1`, Y� STATE C—_ Z 1 Pz(JlD <br /> APN and Use Application # - - h <br /> GOS Dist j Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR — I Y Y"�UII� ____-__ e BILLING PARTY Y // "I / <br /> D3A Ned � �11�- �----- ----- PHONE #1 (��),�- 3-70 <br /> MATLIlG ADDRESS —�(�l�S 1 VY1 LL- I �_------,- -7 FAX # (gl0l ) 333 - <33C)3 <br /> C'TY — l�J 1 STATE V\ _ LIF' <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all siteRAYWIMTt specific <br /> PHSPEED hourly charges associated with this facility or activity will be billed to the party identified 47i jU PARTY on <br /> Page 1 of this form. <br /> DEC 0 41998 <br /> I also certify that I have prepared this application and that the work to be Performed will be done in accordance with all SAN <br /> SAN JOAQUHN COUNTY <br /> JOAQU!N COUNTY Ordinance s and Stan rds, State and Federal laws. ENVIRONMENTAL <br /> HSER ICE ION <br /> APPLICANT'S SIGNATURE . <br /> Title: �� Date: ,0 PAYMENT <br /> RECEIVED <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicebte, I, the owner, operator or al off1Qsp�m.rOf 1e�, of <br /> the property located at the above site address hereby authorize the release of any and all results, geo>Jl�llfchi a4�9f%lor <br /> environmentat/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL IIEALTH DIVISION as soon as <br /> it is available and at the same time it is `prrooviided to me or my representative. PUANJO QUIN SERVICES <br /> Nature of Service Request: J 'l1*`��� �� service Code <br /> 1 / <br /> Assigned to (/' V' Employee # Date <br /> Date Service Completed / / Further action Required: Y / N 3 PROGRAM ELEMENT- <br /> Fee Amount Amount Paid �i Date of Payment Payment Tyre Receipt # Check # ; Recvd By <br /> f <br /> k^/ 00054U Ub <br /> I <br /> A RE-4S /�� / i SLPV _/ / - ACCT ---/ Y� /-- �T CLK <br />