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6–C-1,1–1998 1 :26PI.1 FRU 1 _ <br /> SERVICE REQUEST (EH 00 61) Revised 8123/93 <br /> FACILITY ID a f Y 1 v?�� -k-) RECORD ID M INVOICE N <br /> FACILITY NAM Y' Ui k A S1 \ . 1 .0 BILLING PARTY Y / <br /> SITE ADDRESS –7-Kk) Tom( ,iii_\- <br /> CITY \L Y 1 CA ZIP <br /> OWNER/OPERATOR BILLING PARTY Y / V <br /> �n PHONE *1 <br /> i. DBA � T\. c�'•1�l1\_`�� ,� 1�. <br /> ADDRESS P•O \1JUX �v PHONE 02 ( ) <br /> CITY STATE C_49 ZIP 9,45 S 3 <br /> F APM tt IF Ind Use Application d <br /> BOS Dist location Coda <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOORR vSA/FL�T�Cc�fj �-���{1y� (CY 5�7��5/��Y\��5 ��{ �� BILLING�P�ARRTQY� � / N <br /> DBA/vI ✓ & TV 1l� ✓y���' /� 1� PHONE 01 (LIQ ( -2L4L4C-2 <br /> NAILING ADDRESS P3 o N. P; T f ' ` FAX 0 (�00 R1 <br /> CIT STATE 01 ZIPg J <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of sane, acknowledge that all site and/or project specific <br /> OHS/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. PAY WE W <br /> I also certify that I have prepared this application and that the work to be performed will be done in accord 'WGEI�{k7$AN <br /> JDAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. JUN 9 1999 <br /> i <br /> APPLICANT'S SIGNATURE : � I / <br /> SAN JOAQUIN COUNTY <br /> Title: t �) P ���� hY Date: lC7i�CY��O PUBLIC HEALTH SERVICES <br /> J _MRONMENTAL HEALTH DIVISION' <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition 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 date and/or <br /> environrmntal/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the snore Time it is provided to we or my representative. <br /> Nature of Service Request: / /( � r I Service Code <br /> Assigned to l� lei 1�� V�- ' Employee # r v Date A–V/_I_/ <br /> Date Service Completed _J_/ Further Action Required: T / N PROGRAM ELEIONT �vv <br /> i <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check t Recvd By <br /> 2A 7 PA- <br /> RENS / SINN _J_J ACCT �, / UNf7 CLK —J_� <br />