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• SERVICE REQUEST 0 (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # G 0 -7 RECORD ID # 2 r INVOICE # JJ-31 7 9 q <br /> FACILITY NAME CSRvf-1y' BILLING PARTY / MN ] <br /> SITE ADDRESS acto <br /> CITY CA ZIP <br /> OWNER/OPERATOR OJ no^ V'S 1'I BILLING PARTY Y / N <br /> DBA t CTA� PHONE #1 <br /> ADDRESS , ��1\�,c ��w10 +n Uxn L M`I PHONE #2 )'J4-L - <br /> CITY �Ckyk 0,gv\UA STATE ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> ONTRACTOR and/or <br /> SERVICE REQUESTOR �C t.C1 -���cV\ r1(' BILLING PARTY Y / C <br /> DBA �+L��e�rP«G PHONE #1 6"L <br /> MAILING ADDRESS �� d�+ 1 1�) FAX # ( Sly+ ) `bC1, - %A <br /> CITY <br /> 1 <br /> CITY �� aln a n( STATE C�" ZIP Cl'4' -} <br /> BILLING ACKNOWLEDGEMENT: 1, 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 repared this application and that the work to be performed will be done in a * T all SAN <br /> JOAQUIN COUNTY Ordi ce Codes and ards, St to and Federal taws. RECEIVED <br /> APPLICANT'S SIGNATURE <br /> 51997 <br /> `lv\q Date: 6/Z/DC7 <br /> Title• r[:t �1�r1.� <br /> SAN JOAQUIN COUNTY <br /> ?UBI.IQ HEALTH SERVICE= <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, op g0KMEFf'AAtHMLT"r%iW' <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 <br /> Assigned to �� /l ` c Employee # /f/ Date <br /> Date Service Completed / Further Action Required: Y / N PROGRAM ELEMENT oL05 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS _/ / SUP11 <br /> ACCT ACCT / /"I� UNIT CLK _/ / <br />