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SERVICE REQUEST 0 (EH 00 61) Revised 8/23/93 <br />FACILITY ID # RECORD ID # /�� ()G1 1 INVOICE # o3 lo� <br />FACILITY NAME f (/�&* voA- P dooL,' � L%em 5 15 BILLING PARTY <br />SITE ADDRESS 62 2 3 7 <br />CITY CA ZIP 2f a NU <br />OWNER/OPERATOR /"MGP/t'1}/(% � C6C/iCliYl BILLING PARTY rC/�/ N <br />DBA /VU%'141`S PHONE #1 <br />ADDRESS ( (CJ 1-424 t A, Ck-e PHONE #2 ( ) <br />CITY L � ��� STATE '- ZIP Cl y Q <br />FAPN # Land Use Application # <br />ir BOS Dist Location Code <br />CONTRACTOR and/or J6SERVICE REQUESTOR 6 KI ISOAlAl PC---7-VO ,—fit /nom BILLING PARTY Y / N <br />DBA PHONE #1 (_�) 97F- y - 623 <br />MAILING ADDRESS I 0. FAX # <br />CITY {A' . �!�, tLt(2N' STATE rt4 ZIP l U <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. <br />I also certify that I hav pared this application and that the work to be performed will be done ied?xb��e" with all SAN <br />JOAQUIN COUNTY Ordinance Code and Standards, Statend Federal laws. <br />/A <br />i� �j <br />APPLICANT'S SIGNATURE JULJ U L " �"� <br />ly <br />Title• �(�.l�l - Lt� � `�� Date: / rj--/6 SAN JUAQUIN COUNTY <br />pUBLICHEALTH SERVICES <br />Rqp �ato� or ag ntHEALTH, DIVISION <br />of same, of <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owrie�i' b <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 />49 <br />Nature of Service Request: -;ff0 <br />Lc/%C/ _ <br />Assigned to �--%L Employee # <br />6 c;, C, <br />Date Service Completed _/_/ Further Action Required: Y / N <br />Service Code / <br />Date �/ /q C-� I <br />PROGRAM ELEMENT 7--5- <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />2-34. u--7-)_ <br />- <br />�-9-�U <br />V, <br />1 W5 <br />51/1-- <br />REHS ! // L/ ✓ SUPV_/ / ACCT ( Q� �/ D D / UNIT CLK _/ / <br />