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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br />FACILITY ID # <br />0,_I"FUt6Ny �' 1 <br />RECORD ID # <br />('�. <br />INVOICE # <br />N <br />FACILITY NAME ✓NG��-Gy66p <br />0,_I"FUt6Ny �' 1 <br />1.►" <br />BILLING PARTY Y <br />BILLING PARTY``'i <br />N <br />Recvd By <br />Ci <br />SITE ADDRESS �JU <br />� ` <br />!V lCY'� <br />L Nr <br />CITY (, �..1- CA ZIP <br />OWNER/OPERATOR <br />0,_I"FUt6Ny �' 1 <br />Date of Payment <br />BILLING PARTY Y <br />N 71 <br />Check # <br />Recvd By <br />Ci <br />DBA <br />CH UPt-i Q-A- <br />PHONE #1 ( ) p YZ - <br />q.5 -2-c? <br />O 5a -,-c <br />PHONE #2 ( <br />ADDRESS <br />T ° • <br />CITY <br />S60 �—Amofj STATE <br />ZIP <br />APN # <br />Land Use Application # <br />IFBOS <br />Dist <br />Location Code <br />CONTRACTOR and/or / ,T. <br />SERVICE REQUESTOR FJW JEI- C414S 1 -(� �U( jo/y ` /-C - Je- <br />NW) L BILLING PARTY Y <br />/ N <br />p DBA <br />I ! 11 +J� �OVIJ� C�bo� �+' �� _ <br />�Z - <br />PHONE #1 (�) -372U <br />s <br />MAILING ADDRESS <br />IVW� JZck fort -bw <br />FAX # () 3?2-- <br />07 <br />CITY <br />V061 S�9E,�,8�lC4,JTb STATE W <br />ZIP <br />�i3116 <br />PZ, av% %e% <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, 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 form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes ad Standar State and Federal laws. <br />APPLICANT'S SIGNATURE : hh V 1 v <br />Title I's ev Date: <br />r— <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:rr Service Code <br />Assigned to Employee # V// b 10 Date /—Z / <br />Date Service Completed / / Further Action Required: 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 />Ci <br />� q — <br />a/I� IQ <br />✓ <br />SUPV _/ / ACCT/ UNIT CLK _/T_/ <br />