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SERVICE REQUEST . (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # V (j�(� INVOICE # o ff L/C 3 5 <br /> FACILITY NAME � 0i BILLING PARTY Y / N <br /> SITE ADDRESS 1700 <br /> ITY <br /> CA ZIP33ry RUS04 <br /> C <br /> 11�� <br /> OWNER/OPERATOR ��✓ ' BILLING PARTY Y / N <br /> DBA C Ur�v�,�i� PHONE #1 <br /> ADDRESS / PHONE #2 ( ) <br /> CITY JaGr�menio STATE GA ZIP CIt7?105 <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> `,'SERVICE REQUESTOR :tai'1 C�i� ?(� BILLING PARTY Q / N <br /> DBA r�G� �rL7 PHONE #1 <br /> MAILING ADDRESS I � W FAX # ( �}D )(�q <br /> CITY 60(1C.0rd STATE 6A zip g45ZO <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specf C <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 and Standards, State and Federal laws. <br /> PXIMENT <br /> Mr <br /> APPLICANT'S SIGNATURE =') <br /> Title: f-aC' Date:_ inrn 1 5 1997 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, opera WjQAC* prtt0gAT9ame, of <br /> the property located at the above site address hereby authorize the release of any and all resu� l�Ft�NAAtTFI�I5IVISI�dw r <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: ��'1-�t� a Service Code <br /> Assigned to 'L �` �`�` � Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUPV / /__ ACCT ,/ UNIT CLK _/_, <br />