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SERVICE REQUEST (EH 00 61) Revised 6/23/93 <br /> InLITY <br /> IO # , RECORD ID 0 ! L lNVG10E # <br /> FACILITY NAME C-47 10'n Ar// lar MILLING PARTY Y <br /> SITE ADDRESS A29 7 <br /> CITY CA ZIP �24__3-2 0 <br /> OWNER/OPERATOR BILLING PARTY Y / <br /> DBA �/, C� 7 �US�vN/ GS ��Dn ///phi .�E #1 0 ) 2 -zza <br /> ADDRESS PHONE #2 (_20 „ 77 U <br /> CITY STATE i1 ZIP <br /> APN # and Use Application # = <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE RECUESTOR /W - BILLING PARTY `C / N <br /> DBA M /e<< >� �' t�1 v:iib stitp ✓r PHONE #1 ( )a 7� �375r' <br /> ILING ADDRESSl >- FAX <br /> OCITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of saae, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity wilt 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 wwrk t9 be performed wilt be done in accordance with all SAKI <br /> JOAOUIN COUNTY Ordinance codes and standards, state and Federal tads• NAR <br /> 1998 <br /> APPLICANT'S SIGNATURE <br /> Title: L-44 <br /> 1i�fq`f �iDlvlstpAt <br /> � c Y Date: � ���� �� qb • <br /> 'AUTHORIZATION TO RELEASE INFOWTION; In addition to the above, when appliaakie, 1, the owner, operator or avant of some, of <br /> the property located at the above site oddrska hereby awthgr 4e the release of any and all results, pecteehnical data and/or <br /> 'envirormantal/site assessment lnfaralatign t4 SAN JAAGUIN COUNTY PUBLIC HEALTH IBAVIC96 BNVIRONNENTAL HEALTH DIVISION as soon as <br /> It is available and at the am tine it is provided to me or W representative. <br /> Nature of Service Request: Servide Code d 3 <br /> Assigned to 1J(�"t1� W _t?�-(tY� Employee # Q Date 3 _,��J _ <br /> Date Service Completed / / Further Action Required: Y / N rpR= ELEMENT w3 <br /> Fee Amunt Amount Paid Date of Payment Paylwt Type Ro&eipt # k # Reavd By <br /> zv/51 <br /> AWT f�/ llll.1 T 91X <br />