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SERVICE REQUEST (EH 00 61) Revised_8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # Q (� 3 <br /> G' J � <br /> FACILITY NAME �'S• + lBILLING PARTY Y- / N <br /> SITE ADDRESS WA -) "o r-)?. <br /> CITY �Td [�tJ CA ZIP L J��� - 1,VED <br /> OWNER OPERATOR Qj2opVC'[-5 CD- BIL QHYd P Y / N <br /> INI <br /> DBA foFzO i7 t.tC J:S Cb'- EE' t� ��Sco <br /> P E. - <br /> ADDRESS �� g�-'`� O PHONE #Z <br /> CITY 5&#.j 1✓tiO1J STATE (2A ZIPy=-7 <br /> APN # Land Use Application # <br /> LBOS <br /> Dist Location Code== <br /> CONTRACTOR and/or V <br /> SERVICE REQUESTOR Ki%N w1: b T BILLING <br /> PARTY Y / N <br /> DBA N� t°`(� A- soNS Co NAZU! 00 PHONE #1 (2279 4�- 9314 <br /> MAILING ADDRESS �O � 4�?� FAX # <br /> CITY - T�G� STATE CA_ ZIP 9 152,14 <br /> BILLING ACKNOWLEDGEMENT: 1, 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. <br /> 1 also certify that I have prepared this upplication and that the work to be performed will be done in accord91 <br /> ith all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards State and Federal laws. <br /> APPLICANT'S SIGNATURE : / <br /> ,Ds� OJ. M G►t2-- Date: �O `fl l ` �. ' <br /> Title: i� !" 57IIVJUAQ!iINi,UUNiY <br /> PUBLIC HEA;_:H SERVICES <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, opera- (���-WAi . <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirorc ental/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: A'a J7' Service Code <br /> � lu <br /> Assigned to 0 <br /> Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> e A Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 01 10- q 7 <br /> REN ! / / S 'V _/ / ACCT _/ i UNIT CLK _/ / <br />