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FACILITY lTD # <br />FACILITY NAME <br />SITE ADDRESS <br />CITY <br />OWNER/OPERATOR <br />DBA <br />I. <br />SERVICE REQUEST <br />RECORD <br />«l'2 i�a�INk�r h¢ <br />CA Z.iP 7�s� <br />(Ell 00 61) Revised 8/73/93 <br />INVOICE # ' nal q <br />B1LllNG PARTY Y / N <br />BILLING PARTY Y / <br />PHONE 01 (7/ )U ` Q <br />ADDRESS i ! �! k __ PHONE i72 <br />CITY 1JC ,�.7 STATE _ '` TIP <br />— APN N — Larx! Use Apelir.ation— <br />i BOS Dist Location Code <br />CONTRACTOR arxl/or r <br />SERVICE REQUESTOR`�� — BILLING PARTY ®m/ N <br />DSA - PHONE <br />(.R,0 ) 0 -67 <br />BILLING ACKNOWLEDdEMENT: I, the drxiersigned owner, operator or agent of some, atknpwledge that all site and/or project 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 form. <br />i also certify that I have prepared this application and that the work to be performed will be done in ac r i pp atl SAN <br />1 i .t O <br />JOAQUIN COUNTY Ordinance Codes nci Standards, State and, at Lawn <br />MEL , <br />Title: �/� I Date: �%���� S;. ,u�NTY <br />PIIBL7 H—EALTy SERVICES <br />ENVIRONMENJ q <br />AUTHORIZATI N TO RELEASE iNFORMAT 1:6! In addition to the atx.,ve, when applicable, Il' the owner, operator or"t7lgc t �r I�pN <br />the property located at the above site address hereby authorize the release of any end all results, geotechnical data and/or <br />environmental/site assessment information to SAN JOAOIJIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is available and at the same time it is provided to me or my representative. <br />Fee Amount <br />Amount Paid <br />Date of Payrnent <br />Payment Type <br />Receipt # <br />Check tt <br />Recvd By <br />11o <br />//70 <br />