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• 0 <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # /�/ t/(O 3 INVOICE # <br /> FACILITY NAME 12)A-( I` 1� BILLING PARTY Y / <br /> SITE ADDRESS tDD 2D�U )rA k4 M /\� �>rT <br /> CITY CA ZIP `7 <br /> OWNER/OPERATOR BILLING PARTY Y / <br /> DBA (e`>~C�!�U tv PHONE #1 <br /> ADDRESS //� ��t1)� LJ1 PHONE #2 <br /> CITY �ciLNKt STATE _ ZIP <br /> APN # Land Use Application #--IF <br /> 8OS Dist Location Code <br /> CONTRACTOR and/or i _L/ v 1 <br /> SERVICE REQUESTOR V BILLING PARTY / N <br /> DBA �C1V�S�fll �(1�1'SL/ ,�I Q /� PHONE #1 <br /> MAILING ADDRESS ,��j 27� �- - r-e►ttG 107c >�- FAX # ( Cmc ���- �® g� <br /> CITY c > K�G A STATE l ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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 application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standar s, State and Federal laws. <br /> APPLICANT'S SIGNATURE , <br /> tle:�� Date: <br /> �/rta� /�o <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: Service Code 3 <br /> ve <br /> Assigned to 1 )C�-C,L� (A) Employee # Q J Date _1*— <br /> Date Service Completed / / Further Action Required: Y / N [PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> a3N N a4 y 3570 <br /> RENS/ Z3 SUPV _/ / ACCT / / UNIT CLK <br /> 'r <br />