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SERVICE REQUEST • (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # r� !� O RECORD ID # INVOICE # b3a�O <br /> FACILITY NAME IG Y) 0 BILLING PARTY Y / N <br /> SITE ADDRESS SG �� �• GU�/�c2�b0 �OCi� <br /> CITY S�G,C0/7 CA ZIP <br /> OWNER/OPERATOR S�m 6/z/�//7 dO BILLING PARTY / N <br /> DBA d I2/f//7 O PHONE #1 (c2O�? L- <br /> ADDRESS �J b W CI/c 2/ //�- C/ PHONE #2 ( ) <br /> CITY S17'TJC/6 STATE ZIP 9sa/sem <br /> APN # Land Use Application #F <br /> 80S Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR �'J//� G /� f7�/C/J• �t�Jl. /!//C1� BILLING PARTY Y / �N <br /> DBA ��/�D�'I 04� 4//I C C 2 PHONE #1 ( FZL)33 23-Z/6(9 <br /> MAILING ADDRESS /J !'�-�S/C C ���7 FAX it ( Flbl )3�'3- <br /> CITY GUCS7� S C/2s�/Yl T/7� STATE 60q _ ZIP /S 6 7 <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. — 6 111* 4 ,�y fear , I5 rnWrIG-c� cc�oOV OWhCV2� OPC1`Gci-o�C <br /> Z' we wcrc. no-l" s<N+ pt. I. V <br /> r <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 Mards, State and Federal laws. / <br /> 5C. <br /> APPLICANT'S SIGNATURE / C G �c /C e' <br /> )4- Title: /^G T Date: <br /> AUTHORIZATION 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 me or my representative. <br /> Nature of Service Request: Service Code (� <br /> Assigned to , Employee # Date IIQ <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 3L.1'03 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 3 O-Z, 13 ;Z - I o(�l I q ✓ ���� �.f <br /> RENS / 'l SUPV _/_� ACCT lit Iv / /_'i _ UNIT CLK _/ / <br />