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SERVICE REQUEST 0/JC,6�/ (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # 7 INVOICE 9 <br /> FACILITY NAME C-� �L ` ` ' BILLING PARTY Y / <br /> I <br /> SITE ADDRESS <br /> CITY CA ZIP 5 G S <br /> OWNER/OPERATOR �1� V' L BILLING PARTY Y 7/ v <br /> DBA C7� ''��1� PHONE #1 ( ) <br /> ADDRESS /-S F'/3b1`67 PHONE #Z ( ) <br /> CITY STATE ZIP <br /> Fi4APN # Land Use Application # <br /> r ^ SOS Dist Location Code <br /> L l✓ <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR C =BILLING PARTY / N::] <br /> DBA ��L LN 61z— (16 Qs-mu%C'rI U PHONE #1 <br /> C � <br /> MAILING ADDRESS �D � JI�A�'0�'� .2 Vp FAX # ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHO 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 /> PAYMEN <br /> ' 6 <br /> I also certify that I have prepared this application and that the work to be performed will be done in }DfT/µi all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. MAY -4 1998 198 <br /> APPLICANT'S SIGNATURE "[v JOAQUIN <br /> ENVIPUBLICRONME�TH S&�I ES <br /> Title: p'�v� ��� MA1J/ `�<%� Date <br /> DIVISION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 its provided to me or my representative. <br /> Nature of Service Request: J Service Code ©� / <br /> 0 C-1 <br /> Assigned to E>rployee # C Q Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT l t7 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 11 ?(.P,s-b 5/4-198 ✓ 1��4 (� . <br /> RENS _/� SUPV / / ACCT CLK _/ / <br />