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SERVICE REQUEST � (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # a INVOICE # Q C>?)^L <br /> FACILITY NAME ff'lG' " �`� 112' L` af ` � BILLING PARTY Y / <br /> SITE ADDRESS <br /> CITY % l�t' CA ZIP <br /> OWNER/OPERATOR �7 +� l l �G /Lw `' �`_`� BILLING PARTY <br /> DBA C 7 YI IC/ �O'C�L , G�6 Lig^ � PHONE #1 (cl 10 <br /> ADDRESS O' 1 `� tY 01 ( C/ 0�7 PHONE #2 ( v" t ) <br /> CITY `��I" STATE LA ZIP <br /> APN # IFLand Use Application # <br /> FBOS Dist Location Code <br /> CONTRACTOR and or ?iWTZ 1 Ly <br /> SERVICE REQUESTOR ("� �' � �G F��`�' BILLING PARTY y ! N <br /> DBA P4L7)L�N C'��1 ) +`'L G . PHONE ^ <br /> #1 ( "T�/ <br /> MAILING ADDRESS I l'1 1 ,' G�"" ` ' FAX # ('T64 <br /> CITY f It-7-f kj,"HA STATE ell-lk ZIP — I4!9!�� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> HS/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 accordance with all SAN <br /> JOAQUIN COUNTY Ordinanc4Cand St ards, State and Federal laws. lAPPLICANT'S SIGNATURE � C C <br /> itle• G �.�— C�//°'1-1��/1/ Date:_ Ir/1 � FEB 199 <br /> ,,AN JCAQUIN 0uN T Y <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, oWAbi0 CoH Fb6We V"#E'%f <br /> the property located at the above site address hereby authorize the release of any and all rest fti46bV LFtWf`�6IH��T"APIO N <br /> nvironmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same timeitit is provided to me or my representative. <br /> J <br /> Nature of Service Request: Service Code <br /> Assigned to d,4" ► r'^ Employee # < Date -21--_/—_/ �z � <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT f••iZ J <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENSr, / / - SUPV _/ / ACCT _/DALI <br /> UNIT CLK <br />