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SERVICE REQUEST E 8/23/93 <br /> FACILITY ID # D # INVOICE # 3 1 <br /> W9ILL1:WQ:P:ARTY �J' <br /> 33 3 5 IN <br /> SITE ADDRESS ! t <br /> CITY _ y L�� kt6 < CA <br /> (3WNFR/OPERATOR h " n r c� C) BILLING PARTY Y / <br /> DBA e7 W U PHONE #1 PPJ r ) - ' ' <br /> ADDRESS 7" 7 U l ��xC �r • PHONE #2 < ) <br /> ��� T T <br /> CITY 6c:� '� � STAT ZIP � � � � / <br /> -APN # —Land Use Application # <br /> BOS Dist location Code <br /> CONTRACTOR and/or ,, <br /> SERVICE REOUESTOR / C� (-,j /'1/\ l r ' BILLING PARTY <br /> DBA PHONE #1 f(D(��)C '. <br /> -MAILING ADDRESS j , 0, /`) 87 FAX # (070 V� -� RoG <br /> CITY 7��C STATE C�- tlP % z _ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PIIS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Paqe 1 of this form. <br /> I nlso certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> OAOUIN COUNTY Ordinance C Starxiar Stat a 'Federal laws. <br /> APPLICANT'S SIGNATOR : <br /> Title. Date: <br /> AUT11ORIZATION TO RELEA E INFORMATION: In addition to the above, when applicable, 1, 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 /> envirormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is availeble 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 # �� Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt Cheek-# Recvd By <br /> a 6g5�3o30�0�-4 <br /> RFHS ,/ / SUPV _/ / ACCT �/ a 6/ UNIT CLK _/ / <br />