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6 Ar 1 :26Pn1 FRUI.1 2 <br /> SERVICE REOMST (EN 00 61) Revised 8/23193 <br /> FACILITY ID # ,'/ )I nl� ��lCl RECORD ID # 1'7 INVOICE 0 <br /> FACILITY NAME _ Y' C} l S� hLK� i l ..L .L PILLING PARTY T <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> 0"ER/OPERATOR �0�LL1�Y1 T�`1 •� BILLING PARTY Y <br /> DBA _C Q 0—,- Ch—) l C PHONE #1 (! 45a- <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE CA9_ ZlP QHS <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR end/or <br /> SERVICE REQUES70R�S�.�(L I-C ����Cy C�1 C_\YIl 5�75/\}<�\�S_ ZIBILLING <br /> �PAJR�TYY, /!�N <br /> D&Il/vr S�+ VY� -J LOCI PHONE #1 (-�Vv) <br /> MAILING ADDRESS V;L 3to FAX # do )1 1 -0 135 - <br /> CIT STATE J zip h I <br /> i <br /> BILLING ACKNOWLEDGE KENT: I, the undersigned owner, operator or agent of sable, acknowledge that all site and/or project specific <br /> PHS/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 fora. /� �B <br /> I also certify that I have prepared this apptication and that the work to be performed will be done in accordance RA`Eft�/p�ENT <br /> JOACU(N COUNTY ordinance Codes and Standards, State and Federal laws. RECEIVED <br /> APPLICANT'S SIGNATURE Jo / L G� �- / JUN 9 199$ <br /> Title:'`� C 1� h� Date: �i�,(� / /y SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> AUTHORIZAT(ON TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, 0t <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical date and/or <br /> environmental/site ascessmant information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and At the same time it is provided to Osie or my representativc. <br /> Nature of Service Request: 66U <br /> 1 VLA �) f� Service Code <br /> Assigntd to l/ � J/Vi� C;1 All Employee # tPV � (1 Date 4-1 <br /> 6J J <br /> Date Service�C}ompleted _�_/ Further Action Required: T J N PROGRAM ELEMIEN1 eJV(/ <br /> Fee Amount Amount Pefd Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENSSUPV _J_J ACCT _f J UNIT CLK _J_/ <br />