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SERVICE REQUEST CEN 00 61) Revised 8/23/93 <br /> FACILITY ID M RECORD IDM �` 7�ij 9� =INVOICE M 7 D <br /> .FACILITY NAME �t'1CX+a� BILLING PARTY <br /> SITE ADDRESS <br /> CITY I��nte�'a CA ZIP 1��✓w <br /> OWNER/OPERATOR ToSGo I-'1 ar1�'f"�rG1 �� BILLING PARTY Y / N <br /> DBA ( U / PHONE Ml 1& ) 558- 75-IL <br /> ADDRESS �� V�02JW ay Ave PHONE 02 ( ) <br /> CITY OGT a m��? STATE GA zip <br /> sg00 <br /> APR 0 — Land Use Application M <br /> SOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE RR UESTORand/or Za iq C Vi an iyi0 �Hl- n &rC0 L BILLING PARTY O ! N <br /> f�Qel�rt r �SGO PHONE M1 ( J10 ) 63Cb <br /> DBA `�. `,l <br /> IL1NG ADDRESS 1 �� ► +i �Ow �a�J ��1 � FAX M 5}0( ) 9 L304 <br /> CITY C-rm�ord STATE 6A ZIP 6145 Zo. <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and)oir projects <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identifitaf Ff44IHG PARTY on <br /> Page 1 of this form. R�eF� 1G'f <br /> so certify that I have prepared this application and that the work to be performed will be dorlejiANHSV J ��J <br /> c2) with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. /r <br /> SAN JOA(AuIN U(WNTY <br /> ������ PUDUC hiEALTH Iii iiVIQ= <br /> PLiCANT''S SIGNATURE �� / im <br /> Title: f �rff r O�Cf� Date: 1Z��/ <br /> AUTHORIZATION TO-RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, opergWjBAU!}JARS�08�i§a�//' <br /> of <br /> the property located at the above site address hereby authorize the release of any and all resu4mWaR AL WISISNo r <br /> irormental/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: � itJ4 ti1.1 Service Code 6 <br /> Assigned to �• yXL `—�� Employee M �f Date �/ v/ <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt M Cheek li Recvd By <br /> RENS C�/�/Z ACCT _� UNIT CLK _J__/ <br />