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SERVICE REQUEST / (E11 00 bl) Revised 9/23/93 <br /> FACILITY IDN RECORD Ib N f1 - INVOICE N - <br /> FACILITY NAME U►`- ` (A�I BILLING PARTY Y <br /> SITE ADDRESS // �(� v 1—V/(-CSC- <br /> ►`�' <br /> CITY �1� I�JC�] J ' CA ZIP <br /> ... •.� of <br /> OWNER/OPERATOR BILLING PARTY Y / <br /> DOA Q ® PHONE NI <br /> 1 Lal I <br /> } ADDRESS � C�v �- ��l/i,(��� PHONE N2 ( ) - r'::f•'') <br /> CITY ��7 STATE ZIP qS L30 :k <br /> _ON N —Land Use Application k <br /> Dos Dist Location Code <br /> t 'a <br /> ! CONTRACTOR and/or <br /> SERVICE REOUESTOR 1 �( BILLING PARTYDIIA / N <br /> / PHONE #I <br /> *I` <br /> MAILING ADDRESS FAX N (� / ) /34 <br /> CI1Y ZIP <br /> (�-� STATE , <br /> BILLING ACKNOLILEOGEHENI: I, the undersigned owner, operator or agent of same, acknowledge that all site end/or project speclflC q, <br /> PIIS/END hourly charges associated with this facility or activity will be billed to the potty identified as the BiILING PARTY on. ;t <br /> page 1 of this form. - `s <br /> I nino certify thnt •I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAoUIN COUNTY ordinance Codes and Standards, State and Federal lows. <br /> APPLICANTS SIGNATURE G <br /> Dote: bL2--7 /%� / <br /> title- V( <br /> `. <br /> AUIIIORIZAt ION 10 RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of sane, of <br /> I 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 Informatlon to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION e9 Soon as <br /> It Is available and at the some time It Is provided to me or my representative. <br /> 1 Service Code -- !t <br /> j Nature of Service Recdrest: , <br /> Employee N ? Dote / / c -e, <br /> t Assigned to "` <br /> Dote Service Completed a / Z / ( �' further Action Required: Y / PROCRAM ELEMENT b C0 `;�' <br /> I ;F <br /> Fee Amount Amount Paid bate of Payment Payment type Receipt N Check aY Recvd By <br /> RENS / _/ -ZZ7 SUPV _/ / ACCT _/ / UNIT CLK _,/ / <br />