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9-18-1997 8.15AM FROM <br />P_ 3 <br />SERVICE REQUEST {ER 00 611) Revised 3/23/93 <br />FACILITY ID # RECORD ID $/!/( INVOICE <br />FACILITY RANG <br />/70 <br />qq d <br />SITE ADDRESS�`cP6 � LtJ • )-dG-k4 ,- <br />CITY C t1 cl CA ZIP <br />9ILLING PARTY Y / <br />OUNER/CPERATOR _ _ w` 1, �/�A +L j, C s y -T✓ G . BILLING PARTY • Y <br />DBA T' PHONE 09 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowtedge that att site and/or project specific <br />PH$/END hourly charges associated with this facility or activity will be bitted to the party fdantified as the BILLING PARTY on <br />Page i of this form. <br />I also certify that I have prepared this apptloation and that the work to be performed wilt be clone in aceAdsie1MME SAit <br />XULQUIN COUNTY Ordinance codes and Sty , State rx d oderat taws. RECEIVED <br />APPLICANT'S SIGNATUREBEG <br />Title: d"12'ec�",2 t T-1 /✓l// 4i�y�C�•�v7` �r�'1 Dale: �C �/> 7 <br />-SAN JOAQUIN COUNTY <br />PUSUG HEALTH SERVICES <br />AUTHORIZATION TO RELEASE INFORMATION: In additfon to the above, when applicable. 1, the earner, oper��Vi�Rgi�ent of�� DOf <br />IVISION <br />the Property located at the above site address hereby authoMze the retense of any and all results, geotechnicat data and/or <br />environmantat/site assessment information to SAN JOAWIN COUNTY PUBLIC HEALTH SERVICES ENViRON1e:NTAL aEALTH DIVISION as sows as <br />it Is availahte and at the same time it is provided to me or my representative. <br />Mature of Service BecIpeat: G Service Code <br />Assigned to �!G- t.IC:��L Employee # 6d6. Date /2 <br />Date Service Completed �J/Further Action ReQuired: T / N FROMM ELEMENT P$. <br />Feet AmOCMt <br />H SC 7e <br />Date of Payment Paya mgt Type <br />ADDRESS <br />-,Z bac. , J e- <br />PRONE 02 t_) <br />CITY <br />rL z `ne <br />STATE _ ZIP <br />c� <br />0 <br />Land Use Appticatian # <br />EAPR <br />905 Diet <br />Location Coda <br />CONTRAOR and/or <br />SRCTVICEREOUESTOR' <br />BILLING PARTY j N <br />DBA <br />PROW al#1 t <br />"AILING ADDRESS <br />`i'S�� 7 <br />c <br />FAX <br />CITY <br />e`nd 1,1 STATE ZIP <br />`iS Z <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowtedge that att site and/or project specific <br />PH$/END hourly charges associated with this facility or activity will be bitted to the party fdantified as the BILLING PARTY on <br />Page i of this form. <br />I also certify that I have prepared this apptloation and that the work to be performed wilt be clone in aceAdsie1MME SAit <br />XULQUIN COUNTY Ordinance codes and Sty , State rx d oderat taws. RECEIVED <br />APPLICANT'S SIGNATUREBEG <br />Title: d"12'ec�",2 t T-1 /✓l// 4i�y�C�•�v7` �r�'1 Dale: �C �/> 7 <br />-SAN JOAQUIN COUNTY <br />PUSUG HEALTH SERVICES <br />AUTHORIZATION TO RELEASE INFORMATION: In additfon to the above, when applicable. 1, the earner, oper��Vi�Rgi�ent of�� DOf <br />IVISION <br />the Property located at the above site address hereby authoMze the retense of any and all results, geotechnicat data and/or <br />environmantat/site assessment information to SAN JOAWIN COUNTY PUBLIC HEALTH SERVICES ENViRON1e:NTAL aEALTH DIVISION as sows as <br />it Is availahte and at the same time it is provided to me or my representative. <br />Mature of Service BecIpeat: G Service Code <br />Assigned to �!G- t.IC:��L Employee # 6d6. Date /2 <br />Date Service Completed �J/Further Action ReQuired: T / N FROMM ELEMENT P$. <br />Feet AmOCMt <br />Amount Pa/iidd`` <br />Date of Payment Paya mgt Type <br />Receipt # Check # Reavd By <br />ACCT V) -I � -() /-�-'I 1 UNIT CLIC <br />