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10 <br />SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br />FACILITY ID # <br />Amount Paid <br />RECORD ID #I <br />Payment Type <br />INVOICE # <br />03D�G1�/ <br />FACILITY NAME kcJ P I k GR '.JpiL G -fl�i0 BILLING PARTY Y =/1 <br />SITE ADDRESS I ZZ 5 L0 LF,5,7- Loc 1<r tViQl7 5— <br />CITY ►- U 0 1 CA ZIP <br />OWNER/OPERATOR igaA vat lL t 100- { BILLING PARTY Y / <br />DBA <br />PHONE #1 ( ) <br />ADDRESS 1 7-Z S ;,( h2" T Ln 4r- i < K--04 J S •t __ PHONE #2 ( ) <br />CITY (--U J t _ STATE C- j,4 ZIP <br />APN # =FLandUse Application # <br />SOS Dist Location Code T-1 <br />CONTRACTOR and/or • n <br />SERVICE REQUESTORt/L✓L�( 1/�k f' aC (<� ✓t/L BILLING PARTY <br />DBA PHONE #1 (��- 1�. <br />MAILING ADDRESS !!�r&_c-{G Kc L= E=L e 9L jo FAX # ( ) <br />CITY ✓✓rGTG STATEN _ ZIP <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 />P C t%I <br />I also certify that I have prepared this application and that the work to be performed will be done in accordan 1106 <br />JOAQUIN COUNTY Ordinance Codes a ndards, State an deral laws. �� �" "� <br />SAN UIIy! i,Uu:� • t <br />P'U'BLIC HEALTH <br />APPLICANT'S SIGNATURE ENTAL HEALTH DIVISION <br />Title:- Date: <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: �^� r Service Code <br />Assigned to �Q.(1-Q-�Cj— Employee # �! b C�i �2 Date <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 />REHS _/ / SUPV _/ / ACCT��/ �� / UNIT CLK _/ / <br />