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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # L) _5 c ,- 1 <br /> NVO10E # ,9-3 <br /> FACILITY NAME BILLING PARTY Y / <br /> SITE ADDRESS �nn3 .4L <br /> CITY <br /> CITY /T Ge+�/`Z Y o CA Z I P C 52-t-0 <br /> OWNER/OPERATOR e /A) Y ��� F! F LJd BILLING PARTY <br /> DBA //LL PHONE #1 ( "zd/ ) 3311_ 4-1 k2S- <br /> ADDRESS �' "`� ,` T T PHONE #2 <br /> CITY (�t��v O�3A2 / STATE G� ZIP ( ✓`Z �� <br /> APN # - Land Use Application # <br /> 00 <br /> 3B S Dist Location Code q j <br /> CONTRACTOR and/or ( 7 <br /> SERVICE REQUESTOR �/�l.C/'�f$ �f ¢ 'r ' ` BILLING PARTY Y <br /> DBA `s A4 PHONE #1 ( 209 ) 3 G?- t!p�l�Q <br /> MAILING ADDRESS 3:2-3 c,.) E -7— 4 , FAX # ( ) <br /> CITY 06 STATE CA zip ls� `C a fJ <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and''/or pro ect specific <br /> PHS/EHD hourly charges associated with this facility or activity will be bitted to the party identified as the BIL6NRTY on <br /> Page 1 of this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal taws. <br /> APPLICANT'S SIGNATURE <br /> Title: Date: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and at( 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 <br /> my representative. <br /> Nature of Service Request: �L�^J Gf-��G� / �O<<-- $-U 17-48,1Z-4 Service Code �Z <br /> SITU a Y <br /> Assigned to G CSI- V,6 ,�Q Employee # 0321 Date Q6)/ <br /> Date Service Completed / 3 / Further Action Required: Y / ( N ) [PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> GKA5cr- aq7 &1�1 <br /> REfiS ��/ /��o SUPV _/ / ACCT _/ / UNIT CLK _/ / <br />