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r <br /> E0'J -lulol <br /> • SERVICE REQUEST (SFXWN O) Revised tMI" <br /> FACILITY 10 g RECORD Ib >b! INVOICE <br /> =IN6Tr T / <br /> :AGILITY NAME <br /> SITE AODRESS (4A �fJ i ?QArP <br /> CITY L bmd CA ZIP - <br /> OWNERIWERATOR I �(�I�- PIRbPC6.. <br /> BILLING PARTY ;,�.".r � N <br /> DRA PHONE ! ( _) _-_WY46 <br /> ADDRESS fry 1 J PHONE A2 <br /> CITY C/ j __ STATE _ Zia 7✓�'!' <br /> APN # Lard use Application. <br /> >to5 pise Location Cod, <br /> CONTRACTOR end/or <br /> T / <br /> SERVICE REQUESTUR RILt.IMG PAM PAM M <br /> DBA <br /> MAILMG ADDRESS moi` . FAX <br /> CITY Qi� j� STATE ZIP ! r <br /> 8ILLING ACKNOWLEDGEMENT: 1, the undersigned awner, operator or agent of SME, acknowledge that att elte and/or project specific <br /> Pms/ENQ hourly charges associated with this facility or activity mill be billed to the party Identified as the BILLING PARTY on <br /> Page 1 of this form_ <br /> I atso certify that I have prepared this application and that the work to be pertorfsed fail► be dans in accordance with alt SAN <br /> JoAcUIN COUNTY ordinance Cades and Standards, State and Federal taws, <br /> t <br /> i <br /> APPLICANT' SIGNATURE <br /> fit--- /+r Date- s ` <br /> AUTHORIZATION TO RELEASE INFORMATION: in addition to the abort, when appticable. I, the owner, operator or agent of arae, of <br /> the property Located at the above site address hereby a4thorize the release of any ort! all results. pe+otechnirat data and/or <br /> emelrormental/site assessment information to SAN joAQu1N COUM PUMIC HEALTH SERVICES ENVIROM MAL #FILUM DIVISION as soon as <br /> It is available and at the same time it is provided to w er my representative. <br /> Ratur0 of serviceRequest: service Cods <br /> Date <br /> ASsigned to Enplayee A—-- <br /> Gate Service Completed fwther Action ItecWred: T / N FROb'RJ4ff SLE WW. <br /> Fee Avioutit Amount Paid Dote of Payment PaMmt Type Receipt f Check * ReCvd BY <br /> ACCT !_�� _ UNIT Ctlt <br /> - <br /> ;70,d 812T�--l1?9G Ol ODW3S W06-1 WdOS:?,T Sl%T-170–SC <br />