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SERVICE REQUEST (EN 00 61) Revised 8/23/93 <br /> =FA0 # . REGARD iD # (� tNVGICE '� <br /> I <br /> ILITY NAME �U 1 �� s��lP ,�� BILLING PARTY Y / <br /> --TE ADDRESS as S S' r. F R Ew M OST S t YZ CC+ <br /> CITY 6400- G CA ZIP •/OPERATOR Oode- STOP 1nge1cE-tsSNL BILLING PARTY O / N <br /> DBA PHONE #1 (SI d ) SSS e'Too <br /> ADDRESS n- l2 PfHeNEMe <br /> CITY rzmrnor�T STATE eft ZIP 9ys39 <br /> APN/ # and Use Application # <br /> TBOS Dist Location Code \ <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR W6e1I�bv\ EVIG-�'h refZ) h L L' BILLING PARTY Y / 0 <br /> 48* CUvr�ccc�" - m'i k L-.1= m PHONE #1 ( 9/G )3',�3 - <br /> LING ADDRESS FAX )3?-3 <br /> CITY 11J<_S STATE _�_ ZIP 9S6 �� -PAYMENT' <br /> i9 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of scale, acknowledge that sit site,jVPr� lRgjh&Wcific <br /> PHS/EHD hourly charges associated with this facility or activity wilt be billed to the party identified as the �i[ IJJI��``�hl!(RTY on <br /> .Page 1 of this form. SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEA TH V! <br /> ,I also certify that I have prepared this application and that the w 9 tg W porformod Witt bo 4%w in accordance wtt� a4ti ' <br /> JOAQUIN COUNTY Ordinance Cod and t dards, Stats ano FPilaCat ku;. <br /> APPLICANT'S SIGNATURE <br /> tle- GiogQ <br /> AUTHORIZATION TO RELEASE INFORUTNIV; In 4WItiAn t9 02 aWyo, +rlw gppVcabke, i, the owner, WretQr or agent of same, Of <br /> .the property located at the abgve site addraao hargby aytherizo tits r4lnase of any and all results, geotechnical data and/or <br /> `environmental/site asseBsment inf9SWXi.gn tq SdN 49AANIN DUTY PUgi.IC iiRA{.TN SERVICES ENViROM OTAL NULTH DIVIIIION of soon as <br /> It is avaitable and at the %am tim it is prgwidad tQ ma or W representative, <br /> Nature of Service Requesti = Service Code <br /> c t�Q <br /> Assigned todf Employee 0 Date <br /> Date Service Completed / /�_ Further Action Required: . Y ( N PROGtAM ELEMENT a 3 03 <br /> Fee Amount Amgunt Paid Date of Payment Paysiont T pa Reoeipt d QWk IN Rsgvd By <br /> REHS �/„ / SUPV <_� ACCT s...��/ ull.[T P <br />