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S (J�e,"b,0l) <br /> SERVICE REQUEST CEN 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # p l y 5 a INVOICE # <br /> 7�t1> Al �jL�� BILLING PARTY Y <br /> FACILITY NAME / <br /> SITE ADDRESS 14/.ALooe. <br /> CITY V'11 CA ZIP <br /> OWNER/OPERATOR ;by,2 BILLING PARTY Y <br /> DBA J PHONE #1 (gI4d <br /> ADDRESS 7(/ ( PHONE #2 ( ) <br /> CITY -41t) STATE ZIP <br /> —APN # Land Use Application # <br /> BOS Dist Location Code <br /> �Lj <br /> -- <br /> - I <br /> CONTRACTOR and/or <br /> ICE REQUESTOR n i►�r� L 9�� `��` � of BILLING PARTY l Y1 / N <br /> DBA ��11 �D-^^� PHONE #1 (2E—) - <br /> MAILING ADDRESS I i +0253 "�`" L '-�/ FAX <br /> CITY 60n64>rJ STATE � ZIP 145L'O <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknow Iedg bti44;l) iTe and/or project specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the pA1 19-C&V%Gaf as the BILLING PARTY on <br /> Page 1 of this form. DEC 2 2 1997 <br /> 1 also certify that I have prepared this application and that the work to be performed wwiillbedoJOAQUIN COUNTY naccordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVIr <br /> APPLICANT'S SIGNATURE <br /> i r `A <br /> Title: f?�1.1 fir ��(7 Date!/6/AT <br /> AUTHORIZATION 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 data and/or <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 some time it is provided to me or my representative. <br /> Nature of Service Request: Service Code <br /> o� <br /> Assigned to _ <br /> Date Service Completed /I / Further Action Required: Y / N PROGRAM ELEMENT �J <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> � � ? � c� ,baa/�i ✓ ra-8� �a . <br /> RENS�//_ SUPV �/ / ACCT __/__/ UNIT CLK _/ / <br />