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e e n 3. Y�. - ,,r+ T: ..✓ 3r 't"• a S •a " <br /> .c ^+*c a - t +.."� <:1f �.. <br /> SERVICE'REOUEST <br /> - / <br /> RECORDf �NVOICE�.n� :� gW✓ <br /> �WLIT� 11) :776: <br /> � GG <br /> ,,., „d.. <br /> .,, -• 1 �- s `'..., ,.Y1E�. s t � ^ /ya,.+ s"a► _.fro 'E4, <br /> • a;f_ E.. �� f <br /> ►AGILITY NAMH e. i 44 V <br /> . '�` <br /> i SITE AODRESS A - <br /> S 51} o � '• 'a. T••� ,� "fi.. .`' +�' .ti-' ""'+ aE -. <br /> L SA, $Eae e b y rf3Y a rS r 2irs .a <br /> 1 U� K1n •. ' ' CA ZIP <br /> CITY _ k r; <br /> 21 <br /> f t � r � rr X '�•rr '�, r;•r Sr'� m <br /> nuNr•R/OpERATQRBiIIiNG PARTT�* j � Y ../§a N <br /> PHONE Ni ( ) <br /> DBA <br /> j` PHONE 02 ( ) F <br /> ADDRESS <br /> STATE ZIP , f. <br /> -MN N Lard Use Application s <br /> 13 �^(_ BOS Dist. ;l' Location code , .6 <br /> t rONTRACiOR and/or <br /> sFRViCE REoUESTOR C Gl �► /nG�T NG• BILLING PARTY T ! r N <br /> _ PHONE � 1 (310 -��� <br /> DBA <br /> ADDRESS <br /> H ILING FAX ! <br /> CITY �t/YaKGc_ 6 STATE 'ZiP {0521,' <br /> r <br /> _ �iLLING ACKNO4LEDGEHENT: I„ the undersigned owner, operator or agent of sank, acknowledge that ell site and/or project specifie <br /> w115/EHD hourly charges associated with this.facility or activity will be billed to the party .identified as the BiLLING PARTY on <br /> ' t Pagw t of this form <br /> ii nlso certify that I have prepared this application and that the work to be performed wlll be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards,,State and Federal laws., <br /> t 1' <br /> c APPLICANTS SIGNATURE <br /> �.. ( � Date: [T )mss <br /> C Title: �� t <br /> � �,, • t �. ...- -.o....._. 1 f3... r ..', r. �, S qui., ; .,.,,,.-. _ '+.:.. �.: ..-.. -'a. ,- ._ ,y.: r <br /> AUt110RiZATtOHTO RELEASE INFORMATION: in addition to the above,mhen:appllcable, .t, the owner, operator or agent of same, of", <br /> f `. the property located at the above site address hereby authorize the release of any and ell results, geotechnical data'snd/or.;` <br /> envirormental/site assessment. Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DiVISiON'es.s."' as <br /> It is available and at the same time It is provided to me or my representative. j�4 <br /> Nature of.Service Request: J. Service Code"-If= <br /> • r <br /> A4signed to , Employee K Date <br /> Date Service Completed' /_� Further Action Required• `'T / N. PROGRAM ELEMENT'2d,�`b <br /> Fee Amount Amount Paid '- Oate of Payment`- Payment type ;Receipt * Check 'F Recvd TByt` <br /> RENS /_ r' $IIPrV P% ACCT /�9 R/ UN I CLK w `s, ate•«��, <br />