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1 <br /> ¢ SERVICE REQUEST (EH 00 613 Revised 8/23/93 <br /> fAClLITY ID # RECORD ID # INVOICE # 0 3.0,Z10/ <br /> FACILITY NAME eaBILLING PARTY Y <br /> v <br /> SITE ADDRESS 5 /�5 � 5' <br /> CITY CA ZIP 02-6 <br /> OWNER/OPERATOR BILEING PARTY N <br /> DBAf PHONE #1 <br /> ADDRESS 2 IVO �d l�J �� _rte_ PHONE #2 C ) <br /> CITY STATE�I} ZIP 5 52 26 <br /> APN # Land Use Application # <br /> IFDOS Dist Location Code <br /> CONTRACTOR and/or ,J �r�'Ale�G <br /> SERVICE REQUESTOR L� `'//, BILLING PARTY Y N <br /> DBAk1 Z PHONE 91Q]�' - 4�! <br /> MAILING ADDRESS 1 i <br /> �✓ � , �d l//'E 5 �� FAX # / ) 3�7- I / 3<fp <br /> CITY A- C�rrlQ_ STATE 4L)4 ZIP <br /> i <br /> BILLING ACKNOWLEDGEMENT: 1, 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 acpgd1aarZ ?g q h,_all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. iilliidd <br /> J IpP�f�lop4""'� <br /> APPLICANT'S SIGNATURE SEP D 2 'LQag <br /> L �TJ�� <br /> Title: / �f/7 /Z -C- Date: SAN JOAQUIN Cid;,/N—rl• <br /> PUBLIC HEALTH SERV#CES <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the ownerE%$WQW'EPld4ehir,b#T f,1/p, Cy,4 <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 JOAQUIN 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: \1,UL Service Code <br /> Assigned to : Employee # D a Z 1 Date _/ / 2 <br /> Date Service Completed f /_J / Further Action Required: Y / PROGRAM ELEMENTj_1., 1 <br /> Fee Amount Amount Paid Date of Payment PaymentTy Receipt # Check # Recvd By <br /> SUPV / ! ACCT !/!/ �� / UNI=CLK �/ / <br />