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SERVICE REQUEST 0 (EH 00 61) Revised 8/23/93 <br />FACILITY ID # I I RECORD ID # I 5 7 Q'2 I INVOICE # <br />FACILITY NAME yNiciek(- S��✓��� Cie Ajl E/1-- BILLING PARTY Y / <br />SITE ADDRESS 1 s_5 L1A.JC01,1J rQ�f ,,11 <br />CA ZIP /.2-06 �lJv' ��gl��� <br />5 <br />CITY <br />OWNER/OPERATOR BILLING PARTY / N <br />DBA 4I Y� /? u-IC(%M 0 �v PHONE #1 (Zo ) aQ 2 <br />ADDRESS i !�J /' dV,1.94�0 /?001-1 3� PHONE #2 (2�)�` - 5AP <br />CITY G� ` U STATE CA ZIP <br />APN # Land Use Application # <br />BOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR C /'' ` ` BILLING PARTY Y / <br />DBA PHONE #1 (f <br />MAILING ADDRESS t 0 'eu -cf FAX # 3116 1'6 ) q51 - <br />CITY o �, a M STATE i!!�_ ZIP [ _�- 1 6 2 <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 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 Ordinance Codes and Standards, State and Federal laws. <br />APPLICANT'S SIGNATURE jmwf� <br />n/� <br />Title• a; � �/t°fy✓%�!/C� Date: <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: k- ( V,0 jx-A' <br />Assigned to�f,C���/� Employee # <br />Date Service Completed / / Further Action Required <br />Service Code <br />Date <br />Y / N I PROGRAM ELEMENT —5 <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check <br />Recvd By <br />/# <br />REHS _/ / SUPV/ / ACCT -/ /O� / UNIT CLK <br />U <br />