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O-Uu-1 yytS I :G4r^M r-KU P-2 <br /> SERVICE REQUEST (EH 00 61) Revised 8/23!93 <br /> FACILITY ID # RECORD ID # 01 -7 '5 INVOICE # <br /> FACILITY NAME � i I `ll �Ifi 1��'Gri�,C7 I C ( "I(�tttJl/ .ILt �/1 FBILLING PARTY T / 0 <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> (AMER/OPERATOR l�Q L�1'1 �� L .� BILLING PARTY Y / l_b <br /> i. DBA kz—, Lon I y L:-.C PHONE *1 (�7 tC7) �S - 5Ci <br /> ADDRESS t" .O �� � � PHONE #2 ( ) <br /> CITY `2.-T—Lr ,Z_ STAIE C/n ZIP Gels c <br /> APN # Land Use Application # <br /> FBOSist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTO—OR S�KC -� �TC��C`Yl S 7 S\ IC\��S ZINC _ BILLING PARTY / 'H <br /> PHONE #1 (L40 ( -�L4`I 4c--7 <br /> MAILING ADDRESS N• f ' �l i Y C FAX # ( 100 ) 1 ' i <br /> STATE CA ZIP T) J <br /> 7 <br /> BILLING ACKNOWLEDGEMENT. I, the undersigned owner, operator or agent of seise, ackrawledge that all site and/or protect 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 foray. <br /> a 1AYWENT <br /> I also certify that I have prepared this application and that the work to be performed wilt be done in accordance Ft <br /> JCAQUIN CWNTT Ordinance Codes and Standards, State ar�xi�IFederal laws. <br /> APPLICANT'S SIGNATURE yP _k_�\D Au NOV 16 199$ <br /> G SAN JOA <br /> (]UIN COUNTY <br /> Title: P k' Date: 1\ 1�l/i0 PUF3LIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIQi\; <br /> AUTHORIZAIION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 ne or my representative. <br /> Nature of Seice Reques — — Service Code <br /> ry <br /> Assigned to Employee # l L Q Date / / <br /> t L�O(/ <br /> Date Service Completed _/ / Further Action Required: ,�T ) / N PROGRAM ELEMENT <br /> r � <br /> Fee Amount Amount Paid Date of Payment Payumnt Type Receipt # Check R Recvd By <br /> 'RENS �/� /� SUPV _J�J ACCT ��� FUNITCLK _/�/ <br />