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SERVICE REQUEST . (EH 00 61) Revised 8/23/93 <br />FACILITY ID # <br />RECORD ID # <br />_22 <br />INVOICE # <br />FACILITY NAME Aro, C D TA- O BILLING PARTY Y / N <br />SITE ADDRESS 2G1 (L& eF_ V V A M //y Po� Q' <br />CITY S I oc-t< TO ti CA ZIP <br />OWNER/OPERATOR A 6 if y BILLING PARTY Y / N <br />DBA <br />PHONE #1 ( ) <br />ADDRESS 1 0 R 6E I y �1 A �" � ( " 1 - �� �J P PHONE #2 ( ) <br />CITY S 72 C k0A/ STATE C4 ZIP <br />APN # Land Use Application # <br />BOS Dist Location Code <br />CONTRACTOR and/or l� �+ C n <br />SERVICE REQUESTOR / T K h}� V c,Ify L O �� JN c v BILLING PARTY Y)/ N <br />DBA PHONE #1 (�) Z - 1 G <br />MAILING ADDRESS ��2 Ay� ��' 'Box�3�OLv% FAX # ( ), <br />y� L Sa Cr am no, CA 95 8 23 <br />CITY STATE Ck ZIP ���� <br />PAYMENT <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of that all site and/or project specific <br />PHS/EHD hourly charges associated with this facility or activity will be Gill;ld iothQrty identified as the BILLING PARTY on <br />i B <br />Page 1 of this form. . <br />SPIN Jv�,`j0 1 ,,f: <br />Ir' <br />I also certify that I have prepared this application and that th 1pe i0►med__wi�''! Q e in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br />APPLICANT'S SIGNATURE : <br />Title: /'17 �% 7 — Te2l —Date: I / <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 site address hereby authorize the release of any and all results, geotechnical data and/or <br />environmental/site assessment 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 me or my representative. <br />Nature of Service Request: G. <br />Assigned to /� _ Employee # <br />Date Service Completed / / Further Action Required <br />Service Code �j b <br />Date <br />Y / N PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />7-1�-ys <br />- <br />/ 3// 21 <br />0� <br />REHS <br />ri /__9_/� <br />SUPV <br />�/ / <br />ACCT / / <br />UNIT CLK <br />_/ / <br />