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0 SERVICE REQUEST 10 (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # 5 Z� -F NVOICE # I W/ <br /> FACILITY NAMEbr I, LrI4 _ Z 1_("I., �1`� BILLING PARTY Y / <br /> SITE ADDRESS WT/'4 _t/,�n <br /> CITY �� !.�/ t,to V. CA ZIP <br /> R/OPERATOR t0i4 C i'i + / ll / BILLING PARTY Y / N� <br /> DBA PHONE #1 (01," 010 - 9', /a' <br /> ADDRESSf!� r Vlf/ In IL 72 1 re V,4 � � PHONE #2 ( ) <br /> CITY �T1T/jc Fyn STATE ZIP (g2n <br /> APN # Land Use Application # <br /> 71-FBOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING PARTY Y / N <br /> DBA Atm "P � Y��j '�a(tip ( / Li��. PHONE #1 C e7`v ) <br /> MAILING ADDRESS Fi ►rte 1L �� FAX # (-Z& ) - &V-3 <br /> CITY / �,,���„� STATE Ci/a- ZIP -725,f? <br /> T <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge 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 th <br /> e BILLING PARTY on <br /> Page 1 of this form. i E <br /> NT <br /> ECEIV <br /> I also certify that I have prepared this application and that the work to be performed will be done i or n e w Qt all SAN <br /> JOAQUIN COUNTY Ordinance Code and Standards, State and Federal Laws. 1995 <br /> SAN JOAQUIN��1L)NTY <br /> APPLICANT+S SIGNATURE `n PUIBLIG HEALTH�Ef��ICES <br /> �t I L L JIVISION <br /> Title- IJBWCVI 'n V- __ Date: '� Z —q 5 <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 is provided to me or my representative. <br /> Nature of Service Request: Service Code <br /> Assigned to W+ Employee # -1 —1 n Date -Z_/�/�� <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 /> 'r <br /> REHS / / SUPV / / ACCT / UNIT CLK _/ / <br />