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9J,�* <br /> SERVICE REQUEST PJ1E. 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # 0 dac)L <br /> FACILITY NAME BILLING PARTY Y / <br /> SITE ADDRESS / D 7 �-4y�r�� c.1�U( L✓1j <br /> CITY [Oli�''I�tl CA ZIP <br /> OWNER/OPERATOR ALL, Mob BI LLING PAF�RTY Y / N <br /> �I <br /> DBA _ 4,,B\14 SIT �',�o GuM PHONE #1 ( > ¢3 - 0 SQA_ <br /> ADDRESS d 3 � 1 PHONE #2 <br /> CITY �i�� MkaTn STATE ZIP ¢ <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/orr - <br /> SERVICE REQUESTOR CSN AiG BILLING PARTY Y /ON <br /> DBA /,"I €S PHONE #1 (Jj) <br /> MAILING ADDRESS FAX # <br /> CITY SL~,-e-� STATE _ ZIP <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 bit5th tiyn <br /> the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this plica ion and that the wor bee be donerdance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Stand ds, Stat ederal t ws. M� <br /> APPLICANT'S SIGNATURE <br /> r <br /> TitleJUL 81995 <br /> SAN JOAQui r,r'I <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the ownerP1U60P" pFAc�rr�gS iq`�� dame, of <br /> the property located at the above site address hereby authorize the release of any and alts{ k�f ,� ot�chHr � �',,tyyfd!l&and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVITTTSION�W"bn 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 a <br /> Assigned to mployee # Date <br /> Date Service Completed / / Further Action Required: Y / NPROGRAM ELEMENT Z. <br /> ==A <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> SUP V / / ACCT UNIT CLK <br />