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ftSERVICE REQUEST 10 (EH 00 61) Revised 8/23/93 <br />LITY ID # <br />EC <br />RECORD ID # <br />/ Cj �] <br />INVOICE # <br />Receipt # <br />FACILITY NAME <br />SITE ADDRESS(/C� <br />CITY �^ ^'` CA ZIP !/ <br />BILLING PARTY / <br />OWNER/OPERATOR W d BILLING PARTY (� /CCN <br />DBA ` I'drl1 PHONE #1 <br />ADDRESS lJJ P Eon n 6 U IE& b'dk- PHONE #2 ( ) <br />CITY 1'h4ryl- STATE- <br />ZIP-I�PLi�ca <br />APN # Land Use Application # F <br />BOS Dist Loi <br />CONTRACTOR and/or <br />SERVICE REQUESTOR <br />DBA <br />MAILING ADDRESS <br />r �. Ifl /9 VAd'LW1/ l I )� FAX # ( �)AL �i � <br />CITYC,�aG U STATE ra ZIP q,J�D`5— <br />j* c V <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or proii�� pacific <br />PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified tAe 51LLPRG ARTY on <br />Page 1 of this form. <br />SAN Jr 10N t,3.)UN <br />11. et.W10fis <br />PLYLIC ,FH iNISION <br />I also certify that I have prepared this application and that the work to be performed will be done i�p8lsnce- alSAN <br />.JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br />APPLICANT'S SIGNATURE :�X\N 0`� ��. �Zrv� F L +1 L \ y C -c; cao. a cA, V," <br />Title: S C (fil Date: .� '— L b <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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�:n ,`/►+ �r I Service Code 1-16 <br />Assigned to .LJiI� V�� F([J'�' Employee # V3 Date <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z 3 d <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By , <br />ES1 <br />SUPV <br />_/ / <br />ACCT <br />/ / <br />UNIT CLK <br />