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SERVICE REQUEST v CEH 00 61) Revised 8/23/93 <br /> TaEx'rox H NOssis # INVOICE # <br /> ATTORNEY AT LAW <br /> MCCUTCHEN,DOYLE,BROWN ENER9EN BILLING PARTY Y <br /> CENTER TELEPHONE 116)393.2062 <br /> THREE EM6ARCAOERO FAC=NMILE/M 3)343-2264 <br /> SAN FRANC7X0.CALIFORNIA 9�I II (� <br /> CA ZIP 9SZ&0 <br /> OWNER/OPERATOR S S�4 BILLING PARTY Y / ON <br /> DBA PHONE #1 ( ) <br /> ADDRESS PHONE #2 <br /> CITY STATE ZIP <br /> APN # Land Use Application #IF <br /> BOS Dist Location Code <br /> CONTRACTOR and/or ��� ,,,� <br /> SERVICE REQUESTOR 'fre';1P ` N c)V'r SBILLING PARTY Y / N <br /> DBA I kC Ie-1 �C�(� an{�,1w U��►+ZrSA�'^ PHONE #1 ( 1 S ) p3-�23 - <br /> MAILING ADDRESSl.6alP,rO (_#.�.-fig � OL"1� FAX # <'f <br /> CITYSTATE ZIP <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 t of this form. <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 /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE !' <br /> Title: Asi5oc4'4ke- / Affyvy!:t� Date: 2-Zi 3/9� <br /> AUTHORIZATION_ TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of,any and atL results, geotechnical data and/or <br /> environmantat/site assessment A nformation 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. Yy� <br /> Nature of Service Request: Service Code C��.(O/ <br /> Assigned to `� C� i�., Employee # ®� Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT :3 <br /> Fee Amort Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS _/ / SUPV _/_� ACCT _/ / UNIT CLK _/_� <br />