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SERVICE REQUEST <br />0 (EH 00 61) Revised 8/23/93 <br />[F:A:6ILITY ID # <br />/� /J7 <br />RECORD ID #F< <br />�-;o / <br />INVOICE # <br />FACILITY NAME kF/"1/V / 5ICIWIKI BILLING PARTY Y / <br />SITE ADDRESS 443 W1 &114—CeI" U„ `1M"o at <br />D11 %R l <br />CITY ���/�/�/ CA 21P ��� lG' <br />OWNER/OPERATOR <br />/� /J7 <br />/��� <br />Receipt # <br />BILLING PARTY N <br />Recvd By <br />/Amount <br />.� <br />00 <br />DBA <br />PHONE #1 <br />ADDRESS <br />ILL AIIVZFY <br />PHONE #2 (s)- <br />l/ <br />CITY <br />A/ STATE <br />ZIP 2SG <br />APN # <br />and Use Application # <br />F <br />IF <br />BOS Dist <br />Location Code T--1 <br />CONTRACTOR and/ore7moC <br />► <br />25199 <br />0/ <br />SERVICE REQUESTOR <br />/ tif>`T��� <br />BILLING PARTY <br />N <br />DBA�`� <br />SAN it <br />l PUBLIC HEALTH SERVICE: PHONE #1 (`W_) <br />MAILING ADDRESS <br />!/G� ✓/ <br />/ / � =3%% <br />FAX # (V <br />CITY c7 ���iG//� STATE ZIP 14,2­1Q <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 have prepared this appl'cation and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standa ^, State and Federal laws. <br />APPLICANT'S SIGNATURE : V <br />Title: �A1 A/IFI" - Date: k� 1 e — /-�- �� /1( V 5 -ft <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 />environmentat/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: <br />Assigned to W �p„ � Employee # l t 3 <br />Date Service Completed / / Further Action Required: Y / N <br />Service Code'D3 .1 <br />Date --H- / 7. --�/ S/2 I <br />PROGRAM ELEMENT D� O� <br />Fee <br />Amount Paid Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />/Amount <br />.� <br />00 <br />REHS C�/_�/ SUPV [41ACCT/ / L <br />}� L/ °Z� / UNIT CLK <br />v\ S <br />