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0 <br />SERVICE REQUEST <br />LArILITY III' RECORD 10 N INVOICE N <br />(EN 00 61) Revised 8/23/93 <br />®oueeu®®eue® <br />FACILITY BANE -- V-7l-Ql_'Si-( jzj^ l-.L—C- BILLING PARTY Y / <br />SITE ADDRESS %3aL ;-) . � Lr goon <br />CITY 5=C- \L - M= CA ZIP `95gu4 <br />WNER TOR �Q,�rLl�"ir.L ., .L BELLING PARTY Y / <br />�. DBA T' T i l _ L C . PHONE #1 C'5) O) <br />a ' <br />w ADDRESS P -o, `J� v PHONE N2 ( ) <br />CITY YY\�S `r i_Z STATE �.E ZIP '9-4"5S3 <br />APN # . lend Use Application 0-11 <br />BWDist location cods <br />r <br />CONTRACTOR and/or <br />SERVICE REOASTOR S� T"C�= t^, TC��°"� [Y1 �j-y ��'K�r^Fj� Zl�� . BILLING PARTY T'" / N <br />D C� ! Wi ► V 1 t J V Jl L/C i f .� J/Y !fie PHONE #1 () ` •®K"T <br />NAILING ADDRESS il;�i `+ ✓� . , 1 Y G C/ FAX # 6 ORI i ' ��_� �.L►� <br />r tf <br />CE % STATE ZIP �52 <br />i%LLING HENT: E, the undemigned ower, operator or agent of same, acknowledge that alt site ardor prosect specific . <br />PHS/END hourly chargees associated with this facility or activity wilt be billed to the party identified as the BILLING PARTY on <br />Pape 1 of this fors. <br />I alao certify that I have prepared this application and that the work to be performed wilt be done in accordance with alt SIN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal INS. <br />APPLICANT'S SIGNATURE e u Dc <br />Title: `Q XC� : �v�h% Dater <br />AUTHORIZATION TO RELEASE INFORMATION; In addition to the above, when appticable, 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 alt results, gootLchnical date and/or <br />enviraaaentat/site assessment information to SAN JOACU%N COUNTY PUBLIC HEALTH SERVICES ENVIROWENTAL HEALTH DIVISION as soon as <br />it is avaitoble and at the same time it is provided to arc or my representative. <br />Nature of Service t: r K -A Y U'i"t-iRt Ff_CXM K_ ! service Code i`"iL! <br />Assigned to Eaployee # I Date <br />IMM <br />Dote Service Gaepleted Further Action RoWired. T / N tleorttT -t/(/ <br />Fee Amomt Amant Paid Date of Payment Paymm t Type Receipt 0 Check 9 Recvd By <br />RENS _ .J / SUPV ACCT _ J,,,_ / UNIT CLK / �J <br />