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6-. IJ.. 1998 1 :26Pr.i [--Put I P 2 <br /> SERVICE REWEST (EN 00 61) Revised 8/23/93 <br /> FACTL1TY ID 0 , RECORD IDN �1 � G 61 INVOICE M <br /> FACILITY NAME BILLING PARTY- Y / <br /> SITE ADDRESS <br /> CETT �i`..U�\C \Y\ CA ZIP 1��UL1 <br /> OWNER/OPERATOR �'�✓V�_L�L�� L•1 .� FBLLN(; <br /> PARTY Y / U <br /> OBA u—, Lon l PHONE 91 (�10)" "2 S. c�G-X�) <br /> ADDRESS 1 •C) PHONE #2 ( ) <br /> CITYSTATE C,49w ZIP 9-475 <br /> APN 0 and Use Application # <br /> 1[ --- <br /> r - SOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REWESTOR 5 S—�f �.�T�{Cy ti C YI S�S/\��C.\�\5�,/{Z1 1KBILLING PARTY / N <br /> Dgil/�l ���✓ lam► 1V �t5 �� �T' �S +ter ���' PHONE NI ( ) -24 L4 9 <br /> NAILING ADDRESS' ✓� �. 1 ` ' eC./� FAX 9 (Lvj� )'!j 1 -0 ,�r___ <br /> CIT STATE CA ZIP =J5 I <br /> i <br /> MILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of sacro, acknowledge that all site "/or projeet 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 forst. PAYMENT <br /> 1 slso certify that I have prepared this application and that the work to be performed will be done in accordanPF;(tjF, W- <br /> JOAOUIN COUNTY Ordinance Codes and Standards, State and federal laws. <br /> JUN 9 1998 <br /> APPLICANT'S SIGNATURE <br /> ilia• Cru \ 0 � C � Date: i�/ted/ SAN JOAQUIN C0UN1Y <br /> PUBLIC <br /> HEALTH SERVICES <br /> VIRONMENTAL HEALTH DIVISION <br /> AUTH0RIZJl110N 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 all results, geotechnical date and/or <br /> environmental/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to awe or my representative. <br /> Nature of Service Request: Service Code <br /> Assigned to � � Employee #I Date /_ —/_TL <br /> Date Service Completed _J_� Further Action Required: T / N [PROGRAM ELEMENT 30(12' <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt 0 Check R Recvd By <br /> RENS / SUPV _J_/ ACCT <br />