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3 <br /> ' SERVICE REQUEST �*�,. (EH 00 61) Revised 8/23/43 <br /> FACILITY IO # RECORD ID # ! INVOICE # <br /> r LSC.. l r <br /> 0 9 <br /> FACILITY NAME 7-�(E cj//,)C 1 <br /> BILLING PARTY <br /> SITE ADDRESS -S O L-4 40 <br /> CITY .5 77)e-K z ^ CA ZIP <br /> �-7:2 <br /> OWNER/OPERATOR BILLING PARTY Y <br /> DBA if f/� 7�K- p��(i~-S C0 PHONE #1 c Zd 9'-/11- — <br /> ADDRESS D ' p PHONE #2 <br /> CITY 112 T 1PDf STATE G4 ZIP 9 S3�(0- o15:27 <br /> APN # Land Use Application # <br /> 8OS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR BILLING PARTY Y / N <br /> DBA RECEIVED PHONE #1 ( ) <br /> MAILING ADDRESSFAX # ( ) <br /> PUBLIC I TEAL-lr COUNTY <br /> CITY 5fx[V$1R �r ALZI `r�iC.,_S <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, 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 a~ T all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. IIfRECEIVED <br /> APPLICANT'S SIGNATURE : - JUN 5 199.5- <br /> SAN JOAQUIN COUNTY <br /> Title: Date:- - ar IRI IG HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIO'� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, o <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUUIN COUNTY PUBLIC HEALTH 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 Code S2Z <br /> i . <br /> Assigned to � ' 0I Employee # O 3 a--r Date <br /> Date Service Completed � 7 q / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> at - '0 ) /s,�. , IF"- O.56ff7 C <br /> [REHS 6 / : / X75 SUPV _/ / ACCT /,,,,-�L-/-�5-- UNIT CLK _1 / <br /> -L <br /> U <br />