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EFACIY SIJ # <br />FACILITY NAME <br />SITE ADDRESS <br />CITY <br />OWNER/OPERATOR <br />1;:. DBA <br />SERVICE REQUEST <br />RECORD ID # l� <br />Ila N M ye <br />CA ZIPHV <br />(Eli 00 61) Revised 8/7.3/93 <br />INVOICE #( ud <br />BILLING PARTY �.�Y---./�� <br />FBI <br />LLIH^ G�r Y / <br />PHONE #1 ()� <br />I� <br />ADDRESSPHONE #2 ( ) <br />----+J' ^^-^---^ <br />CITY _JC�L �: STATE _ Zip/ O 0 3z;; <br />- APN N -Land Use Application # -••— '-" <br />BOS Dist Location Code <br />CONTRACTOR aril/or <br />o STOR I Y 4er � -^-- BILLING PARTY � / N <br />SERVICE RE UES/ � �— <br />DSA W._ PHONE /fi (SICK )& <br />MAILING ADDRESS Q 4ta �47gse o D FAX # <br />IRP-) y <br />CITY. C ram - - S1ATE� ZIP�(�[� <br />BILLING ACKNOGILEOGEHENT: A, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PNS/END hourly charges associated;with this facility or activity will be bitted to the party identified as the BILLING PARTY on <br />Page T of this form, <br />PAYMENT <br />I also certify that I have prepared this application and that the work to be performed will be done in acc gfty+ •" SAN <br />i <br />OUIN COUNTY ordinance Code nd Standards, State arrJ at law:;. = w <br />JUN 2 1 1995 <br />APPLICANT'S SIGNATUREfu;UTY <br />f _ PUBLIC HEALTH SERVICES <br />Title: �/ Dater 2 ENVIRQNMENTAL HEALTH DIVISION <br />AUTHORIZATI N TO RELEASE rNFORMATION,, In addition to the alxwe, when opplicahte, l; the owner, operator or agent of same, of <br />the prorK rty located at the above;site address hereby authorize the release of any and all results, geotechnical data and/or <br />ehvironma_ntal/situ assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is avaltable and at the same time It is proviOW to me or my represenca n ve. <br />Nature of Service Request: V <br />Assigned to /'( /(,Y�.��VY _ _ Employee # <br />Date Service Completed / / Further Action Required: Y /; N <br />F?e Amount <br />I <br />Amount Paid <br />6 Zy <br />Date of Payment Payment Type Receipt # <br />6 - Zf Is- - c.--e-4— <br />Service Code <br />Date <br />PROGRAM ELEMENT <br />Check # Recvd By <br />F <br />HS /�//� SUPV _/ / T ff ACCT�--�`� /_�/ UNIT CLK rT/ <br />