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` ZB'd �lili]l <br /> SERVICE REMEST (SERVREA) Ravi NO SIMM <br /> FACILITY IO # RECDRD ID # INMti[CE # <br /> r =AC:CITY WANE <br /> BILtIMI: PARTY : r :• <br /> Si TE ADDRESS IV fi v`owLf�� --- :• , <br /> �J f lJL/IL.[lJ CA L(P ? ' <br /> CITY _ <br /> OVNER/OPERATOR )TULA i ptq0 c� 7 _ BILLING PARTT.': � / N <br /> ORA PHONE #1 f-zeJ --T--W946 <br /> ADDRESS _J r `ir� � i0 1 G S — <br /> CITY STATE ZIP <br /> ppµ # Land Use Application / <br /> SOS Dist Lotatien Cad. <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR eo BILLING PARTY <br /> DBA Pit K *1 { )J <br /> w i,[Nu ADDRESS / FAX # f J <br /> CITY //rm STATE 44ZTP .0 � <br /> SILLING ACKNOWLEDGEMENT: 1, the un&rsigned amer, operator or agent Of 8012, acknowledge that all site sldlor project specific <br /> PHS/ERD hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY an <br /> Page 1 of this form. <br /> I also certify that I have preppred this application and thet the work to be performed will b! done in aoeordence With all SAN <br /> jOA(Ullt COUNTY Ordinance Codes mid Standards., Stat! and Faderst laws. <br /> c <br /> APPLICANT' SIGNATURE <br /> Title- Date! i <br /> AUTHORIZATION TO RELEASP INFORMATION: in edditian to the above, when applicable, I, the owwr, operator or SW- of salsa, of <br /> the property located at the above site address hereby authorfzr the release of any and all rawtts, geotechnfesl tints and/or <br /> environmental/site assessment information to Sri JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROI NTAL LTH DIVISIFJI as som as <br /> It is available and at the sane time it Is provided to me or try reprrsentstive. <br /> Nature of Service Request: 0 Service Oso <br /> A59fgned to Employe@ # _ Det@ <br /> Date Service CompletedFurther Action Required: T / R AAfIGRIiI! ELE '.•'''3 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check#.. ReCvd By . <br /> REHS MIT CLl[ <br /> a d 82 ti2r•9t, 01 0=11,1313 140,t:A WcEZ:SO S66T-6e-Z0 <br />