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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # /q3 =INVOICE # -7 <br /> FACILITY NAME lam/ e p—, `b1" p "-"�"'�� BILLING PARTY1�" / N <br /> SITE ADDRESS <br /> CITY CA CA ZIP /�✓ <br /> ul' i©rcp5* C"i�VLILArY'uu� 1/L� K `C.l ��'""2'` BILLING PARTY c / N <br /> OWNER/APlRkfiOR <br /> DBA ��( OZ%l �/V i�--� 7� c� s PHONE #1 ( G� ) 1 f - 1, <br /> ADDRESS .��X ` PHONE #2 <br /> CITY � STATE ZIP <br /> APN # Land Use Application # <br /> IFBOS Dist Location Code <br /> CONTRACTOR and/or ` ' } <br /> SERVICE REQUESTOR �wCL �� ` BILLING PARTY <br /> DBA / ° � rb PHONE #1 (22�_)c� <br /> MAILING ADDRESS , e �. /� 1© FAX # <br /> CITY r J I_/1r4eC e1"-- STATE-e— ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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 Ces and Standards, to and Federa laws. PAYMENT <br /> APPLICANT'S SIGNATURE "- <br /> Title• �� 1 Date• DEC 3 <br /> SM J0AWN Cf"TV f <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I the owner o )S'!G HtUgtT L-�f�bi J <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: Service Code <br /> Assigned to V. n 1 1 IAV Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 23l��1 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> /W 3$ n.5- CtL, � � <br /> EESUPV /_� ACCT _f i -' / UNIT CLK <br /> — r <br />