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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY Iq # ®O RECORD l0 # 10 INVOICE # 03,P,b-& <br /> FACILITY NAME O Cz IG Y1�C`� ��--� BILLING PARTY Y / <br /> SITE ADDRESS _ SG �• GU�/rr 2��D Rorz <br /> CITY S�G,� TP/�J CA ZIP � <br /> OWNER/OPERATOR S 9 M 6 Z2/ / o BILLING PARTY / N <br /> PHONE #1 (c,?Z <br /> DBA _ OR��//"I O' <br /> ADDRESS `�o �l 15 CiyC1!e e/0 RQ Q1 PHONE #2 ( ) <br /> CITY s Tvc/�- / U/7 STATE (f/q ZIP <br /> APM # Land Use Application # <br /> BOS Dis Location Code <br /> IE- <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR y / G C 'C. Ch// <br /> . BiLLtNG PARTY Y / QN <br /> DBA W / C C C, PHONE #1 <br /> MAILING ADDRESS � 3 ®ZFAX # <br /> CITY (,UC57� �� 12irI/)'1 T/9r� STATE 45A_ ZIP 95 d 5;7Z <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project 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 form. — f3iltin - far+ IS T`nW l`�Cec� u(oov J OwrcVz/ orcra�{-o l2 <br />= W G. w Cr c- n'-t• s cv%+ IP-6• I. <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 Cod and tai ands, ,State and Federal laws. t•HYMEN) <br /> • e-n F C". � w <br /> APPLICANT'S SIGNATURE <br />_ �, Date: ©L OCT 41996 <br /> Title: /^ <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, h�11�N rel I'ope[ato�rj,% REMnt�,of soma, of <br /> the property located at the above site address hereby authorize the release of any and altr�e�d�l�Es',Tgag4ephr�i������i���te�rand/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. y <br /> Nature of Service Request: Service Code 0 _> <br /> Assigned to �. Employee # N �� Date <br /> 07 V <br /> 'Further Action Required: Y / N PROGRAM ELEMENT sL� <br /> Date Service Completed / / � <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS /�O /�_ <br /> gUpV _/—_f ACCT /U/ 7 / 96 UNIT CLK _/_J <br />