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6 SERVICE REQUEST 0 (EH 00 61) Revised 8/23/93 <br />FACILITY ID # 1 �-G1oto�ICRECORD ID #�����]INVOICE # <br />AGILITY NAME �f T eta � - — `ESy} BILLING PARTY Y) / N <br />SITE ADDRESS (cl �1 �. [JoLL� <br />CITY CA ZIP -5; � <br />OWNE APERATO <br />DBA <br />ADDRESS <br />BILLING PARTY <br />y Y / N <br />PHONE #1 (ZZ IG ) /&,56 <br />PHONE #2 ( ) <br />CITY STATE ZIP <br />APN # Land Use Application # <br />SOS Dist Location Code <br />CONTRACTO nd/or _ <br />SERVICE REQUESTOR- 1I�TaIS��—'�1CTtlriA� BILLING PARTY Y / N <br />DBA PHONE #1 (ZL-) q ) - <br />MAILING ADDRESfU ( ,I % (C� —' ' FAX # ( <br />SZia) 6 o` -S � C <br />STATE ZIP <br />BILLING ACKNOWLEDGEMENT: <br />I, the undersigned owner, operator or agent of same, acknowledge <br />that all site and/or project specific <br />PHS/EHD hourly <br />charges associated <br />with this facility <br />or activity will be billed to the party <br />identified as the BILLING PARTY on <br />I <br />?age 1 of this <br />form. <br />r- <br />I also certify <br />that I h <br />a lication <br />and that the work to be performed will <br />RRPAnnYM--''EN <br />be done in hdF�ndVsFt� all SAN <br />JOAQUIN COUNTY <br />Ord nanc <br />oResandta ards, State <br />�Eederal taws. <br />OCT <br />1 6 2000 <br />APPLICANT'S SIGNATURE <br />-tAN <br />JOAQUIN <br />�n\E�'� <br />- <br />�� �-�`— <br />Date: j0 r /D <br />COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH <br />Title: <br />J <br />DIVISION <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 same time it is provided to me or my representative. <br />Nature of Service Request: \CV/tea,C) V7 rj r11VI-6--)ry-c� <br />Assigned to� J _ Employee # O v J?YD L <br />Date Service Completed / / Further Action Required: Y / N <br />Fee Amount Amount Paid Date of Payment Payment Type Receipt # <br />S� l 00 Aa (., /. a)- �0/i�-/ffj <br />Service Code L(y <br />Date <br />PROGRAM ELEMENT <br />Check # Recvd By <br />1.3100 Vn4 <br />REHS// <br />SUPV <br />_/ / <br />ACCT <br />_/ / UNIT CLK <br />_/ / <br />