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N SERVICE REQUEST • (EH 00 61) Revised 8/23/93 <br /> FACILITYID # ,RECORD ID # INVOICE # <br /> FACILITY NAME �U�� s��P �r`j' I BILLING PARTY Y / <br /> SITE ADDRESS 119 VJ' Lo L) I'S IF AWW157- <br /> CITY M/-," TE2!& CA zip Q5-334 <br /> ER/OPERATOR C�2V�4C 5�P , f'NL BILLING PARTY c) /:N:71 <br /> DBA (SMI PHONE #1 ( 5-1c) ) - SSaD <br /> 'fin b� <br /> ADDRESS 1"•�• ©�� S�¢S PHONNE #2 (5-10 <br /> Fefto STATE t✓ ZIP �S <br /> CITY F _FAPN # Land Use Appli--ation # <br /> 2 1� _ (O _ 43 BOS Dist location Code <br /> CONTRACTOR and/or '•"� <br /> SERVICE REQUESTOR � C✓ fA'� v� <br /> C) L_—C. o d BILLING PARTY Y / <br /> DBA Wil(,-nDJ /i66-67-41J I/v G • PHONE #1 <br /> MAILING ADDRESS ' i'I '� ' ►✓dX �ozS FAX # <br /> CITY WET �)i cG�," � STATE CA, zip j <br /> B1lLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknow edge 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 /> we wcrc. no* SCA+ <br /> 1 also certify that i have pr9¢ared tA application and that the work to be performed will be done in accorrfLr1}t SAN <br /> JOAQUIN COUNTY Ordinance Codes S rds, State and Federal Jews. ®�/At-r% <br /> APPLICANT'S SIGNATURE DEG 4A 1997 <br /> /0 <br /> N JOAQUIN COUNTY <br /> Title:— R tZG{�{' Dee T. ��}„/;�(>�L—UAI}CZo*� & 6&4ate: UBLIC HEALTH SERVICES <br /> ENVIRONMENTAL H ALTH OI ION <br /> t <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent OT Sam, <br /> �� <br /> the property located at the above site address hereby authorize he 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: t Service Code <br /> Assigned toy, Employee # --2,;1 Date Z-2- / <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 2-C- SUPV /_� ACCT / / / UNIT CLK _/ / <br />