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} . SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD 1D # `' S INVOICE # 0�0 to <br /> FACILITY NAME au)'K_ I © P T P,--k 6y" BILLING PARTY Y / <br /> SITE ADDRESS <P, _�, 2J �� Froom S4rc<-A- PAYMENT <br /> L �[[ 95- a 0s RIECENF <br /> CITY �7 b C �T Gn CA ZIP <br /> /� /� -T / 77) <br /> J U L 15 1997 <br /> OWNER/OPERATOR ("/'U/r� / C2/�Os9/'912/i , - BILLING PARTY / N <br /> G vn'T�1c-T SA JOAOXCOUNTY <br /> DBA IVA PHONE #1 ( h <br /> 4/5 Bo <br /> Boy, S e F2c►mrte• , <br /> ADDRESS 7`S 6 4EIQ-7"E �-- / 2Z,S td "5-//I9=/�-- PN6NE #2 (,510 <br /> CITY FQ L moy\T STATE J9 ZIP 9 Y-6-13 8 <br /> APN # Land Use Application # <br /> /�/- �j` F BOS Dist Location Code <br /> CONTRACTOR and/ort ` nn ,.yJ <br /> (SERVICE REQUESTOR /y�LfL�E �ea 1912C12KJ,�,oI, /®1��� BILLING PARTY Y / �l <br /> � �.U�! T�rI ��J !9'/�S ��/�/✓I CTI C . PNONE #1 ( ) 3 3-_1� <br /> MAILING ADDRESS 883 s+�-/.5 h � ,4fi U� FAX # (1 ` 3�3- /Z22 <br /> CITY /,(�,�5/ `SA�.t�A �AA2 STATE � ZIP f / <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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. (31IIin6- PGv+� 1s mv%riced iAbouc- ) ��Grrz/o�c�Gf�afz. <br /> W G wCrC_ nc-t 5CrA+ jp,�t• �. <br /> I also certify that I have prepared this application and that the work to be performed will be done in ccordaronce with all SAN <br /> JOAQUIN COUNTY Ordinanc Codes.and St idards, State and Federal laws. PAYMENT <br /> RECEIVE <br /> APPLICANT'S SIGNATURE 1 E <br /> L161997 <br /> Title: C G C, Date: <br /> . SAN JOAQUIN COUNTY <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, IMPWERAW-TT11�1Sne, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data aor <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 timeit is provided to me or my representative. <br /> Nature of Service Request: l7 O ) E Q ' IAre 'Lkik Service Code <br /> Assigned to I P)r Employee # lr�['y(! Date -Z—/_ A0/ 2 <br /> 3: <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMER' <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS Z/� <br /> V71SUPV /_� ACCT I �/ + / _ UNIT CLK _/ / <br />