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MJ q4 PZ <br /> SERVICE REWEST (SERVREO) Revised 8/23/03 <br /> rACILITY ID N JJ�� RECORD ID N INVOICE IF <br /> rar.ILITY NAME /"/��1 ,/�7 BILL INO PARTY 7 / X <br /> SITE ADDRESS / � //'-� <br /> I / L' 2 c <br /> CITY �6 CA ZIP / l 2 2 d <br /> n1WNFR/OPERATOR A� / BILLING PARTY Y / N� <br /> z <br /> DBA r� 00 PHONE M1 ( ) <br /> ADDRESS \J�� PHONE 02 <br /> ) ( ) <br /> CITY � �-1� STATE C14 ZIP <br /> FAPN M Land Use Application M <br /> BOS blot location Code <br /> r0NTPACTOR and/or <br /> SFRVICE REOUESTOR /`l ��– ( BILLING PARTY 7Y / <br /> / N <br /> oBA �j��!i/�� L9 //Lem /G9 // PHONE M1 �1�I ) C �Z— 7 <br /> NAILING ADDRESS 75j -2— ! 12-e // 'jam' / G� FAX K t ) <br /> CITY 14 cir Y7'T STATE �' 1 ZIP <br /> 7 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHD hourly charges associated with this facility or activity will be billed to the party Identified as the BILLING PARTY on <br /> Psge 1 of this form. ' <br /> I also certify that 1 have prepared this application and that the work to be performed will be done In accordance with all SAN <br /> JOAWIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE e� � ,/ems, �21, �p <br /> Title: �h�1+ LeAW— Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In additfon 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 all results, geotechnical data and/or <br /> mvlrorwntat/site assessment Information to SAN JOAOUIN 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. r' <br /> Nature of Service Request:,�( rrOO/��/%t// -�/ / �7 j�/STI % Service Code Assigned to ,eb No%&—rn /y, Employee M 669 Date / /! <br /> Date Service Completed / J / ! // Further Action Required: Y / (1� PROGRAM ELEMENT <br /> ree Amount Amount <br /> Paid Date of <br /> Payment Payment Type Receipt 0 Check IF Recvd By <br /> RFHS / / ° SUPV _/ /_ ACCT / a / UNIT CLK _/ /_ <br />