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.01-17-1996 09:33w FP0[ rO 15108958426 P.02 <br /> f ' <br /> SERVICE REQUEST SEH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD FD # 0�� C� LNVOICE # <br /> FACILITY NAME u a �� BILLING PARTY Y <br /> SITE ADDRESS <br /> CITY I VL1u V��{ rc` CA ZIP 11% Y7)� <br /> t <br /> I <br /> OWNER/OPERATOR R�1 fie_ �(- OL\C 'C� BILLING PARTY Y / No <br /> U <br /> N\ <br /> DBA PHONE #1 (1l S <br /> ADbRE5S -- �n�� <br /> PHONE #Z <br /> CITY �{j �c�\V��` STATE �A ZIP (b <br /> APN NF and Use Application # <br /> LM=D <br /> ist Location Cadc <br /> I <br /> CONTRACTOR and/or <br /> SERVICE REGUESTORC.G �Q �(� BILLING PARTY � / N <br /> DBA PHONE #1 ( SCd ) o I S <br /> MAILING ADDRESS I`��� �Ja`�� �� FAX <br /> CITY <br /> STATE C ZIP l} S <br /> Ii <br /> BILLING ACKNOULEDGEMENTt 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EBD 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 <br /> I also certify that F have p(pa,ed t is a lication And that the work to be ` dancXV E l SAN <br /> PP performed will be done in accJOAQU1N COUNTY Ordinance Codnd a -�tat��rxf-federal-lartE. F�7 u'� t ' <br /> J4 q q <br /> APPLICANT'S SIGNATURE / NOV 2 4 1995 <br /> Title: SAN ypAOUIN COUNTY <br /> Date: PU LICHEALTHSERVICES <br /> ONMENTAI_HEALTH DIVISION <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 aite address hereby authorixe the release of any and all results, geotechnical date end/or <br /> envfronmental/site Assessment Information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It 19 available and at he same time 1t is provided to me or my representative. <br /> Nature of Service Request: (/f'Gt--A4e Service Code ` <br /> Assigned to l Employee # C?t9,&,. Date <br /> Date Service C `�. <br /> anpleted Further Action Required: Y / N PROGRAM ELEMENT 2 3i <br /> I <br /> Fee Amount Amla.mt Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> rt-- cl <br /> I <br /> SUPV _/ / ACCT �/ / UNIT CLK / <br /> -- _ - --J <br /> h <br />