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SERVICE REQUEST (EH 00 61) Revised 883/93 <br /> FACILITY ID RECORD ID # INVOICE B <br /> 11 <br /> GG�n^ Q' Q � � <br /> FACILITY NAME �V[�+N �'S' +—9� t— BILLING PARTY Y I N <br /> SITE ADDRESS �x, <br /> ���1,ww�� - <br /> CITY .TJI�d�/F�"TQil� CA ZIP 11 � <br /> t EIV . <br /> 01lNER ERATOR C tcwF4N r T``'I�VC`r"S ' l,.0• BILQHI�P Y :. / N <br /> ,per Cb EN Ri�S r BSc <br /> DBA GI Ei✓�EZ�t, ` r-anL4cTS <br /> PE <br /> - PHONE tt2"( 1'�l `1 .2.L? <br /> ADDRESS g <br /> CITY <br /> sdfs �b/hOfJ �,"$ STATE �.: ZIP <br /> APN If Land Use Application <br /> BOS Dist Location—Code. <br /> CONTRACTOR and/or <br /> J. 1�I1cNt7T; BILLING PARTY 'Y <br /> SERVICE REQUESIOR I"'�� <br /> DBA W1=l•[I7r NS CO go 1 RUC�ON PHONE ill (l.o9 ) - 9310 <br /> MAILING ADDRESS FAX #- <br /> Cl TY t roCKTO� STATE( CA ZIP �s <br /> YM <br /> BILLI11 NG ACKNOWLEDGEMENT 1," the undersigned owner, operator or agent of same, acknowledge that sit sitelA T02 7specific <br /> PHS/EHD hourly charges associated with this feciCity or activity wilt. be billed to the party identified as the BILLING PARTY on` 7 <br /> _ <br /> Page 1 of this form. '` PU tCEiI R'- <br /> &i�►tl: TH PtVI tON <br /> 1 also certify that I. have prepared this application and that the work to be performed wilt be done in. alt SAN .. <br /> JOAQUIN COUNTY Ordinance Codes and Standard State and Federal, toxP � v <br /> ;er ` r '•'r <br /> APPLICANT'S SIGNAIL <br /> TURE ` t <br /> ♦F z F <br /> Title 112.®J. M GtL- Date. <br /> i ,..• r ^'.. ,. -6.#::.' Y ,` Hwy y1F0^ltT3dAt <br /> AUTHORIZATION TO RELEASE INFORMATION." In addition to the above, when applicable, I,.,the owner, operator or agent of same, of s <br /> the property TO <br /> at the above site address hereby authorize the release o€ any and alC�`},[esults,_ geotechmcaldata and/or <br /> environmental/site assessment. information-.to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL WEALTH DIVISION as soon as <br /> itis.available and at the same.time it is provided to me or my representative <br /> -. > <br /> Nature of Service Request: <br /> Service Code <br /> Assigned to Date, / _ _ <br /> J <br /> ,� <br /> Date Service Completed / / ' -�;' `Further Action Required ! ` N PROGRAM ELEMENT <br /> t..... <br /> - ;.-.. ....... -. s-..;r' <br /> FR <br /> Eee Am« mount Paid Date of Payment Peyment,Type Receipt # Check # vd8ufaJA> .a r <br /> 7 <br /> REH3 y�/ / SUPV _/ / ACCT <br />