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SERVICE REDUESi (ELI DO 61) Revised 0/2 9 <br /> INVOICE a PA MENT <br /> FACILITY ID N <br /> - 1 <br /> FACILITY NAME � <br /> SITE ADDRESS 40 SAN 1pA0UINCOUNTY' <br /> PUBLIC HEALTH SERVICES <br /> City ��(�1 CA zip ENVIRONMENTAL HEALTH DIVISION <br /> 04NEA/OPERAI011 1-4-4 5/LI-11-0 BILLING PARTY YF-- <br /> / <br /> DBA <br /> _ SffflU L-ES�/ !�`577�1� bNd,r <br /> ('l aNONE 02 ( ) 4'70 - S 7)q ' <br /> ADDRESS <br /> CITY _ / "r-I�' `�� STATE 1r <br /> S11P <br /> i. — <br /> __ <br /> AP" M ---------- {{{----���Land Use Application Icnt Ion N ; <br /> ------- 1 — --- DOS blst Location Code <br /> Cf.)WRACTOR nixl/or <br /> SERVICE REnuES1oR BILL NG PARTY �Y� / N <br /> StT/1 Vvll�fS Y ��T'I-7 PHONE <br /> DRA r+`; <br /> 7 i- <br /> C�� �f�US" '��%fir✓ Fax a ( �tJ �) 4 8 r9F` <br /> NAILING ADDRESS q �7 <br /> SCF- Z�� STATE G,�-- 11P ( / y <br /> CITY - � <br /> BILLING ACKNouLEDr,EMENt: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specifiC <br /> PNS/E11D hourly charge s nssocleted with this fncility or activity will be bitted to the party identified an the BILLING PARTY on . t;.,. <br /> Page 1 of this form. <br /> lot, and that tine work to be performed will be done In accordance with All SAN <br /> 1 also certify that I have prepared this applicnt <br /> JOADUIN COUNTY ordinance Codes and Standards, State and fele lows. <br /> a <br /> •r <br /> APPLICANT'S SIGNATURE��IIG �`' -�`—��" - `,7 - <br /> title: — bate: /-6 / � <br /> AUllioRIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of some, Of <br /> the property located at the nhove site nrklress hereby authorize tale relense of any and all results, geotechnical date end/or.� <br /> environmental/site assessnn_nt inlonnation to SAN JOAOUIN COUNIY PUBLIC IIEAI.IN SERVICES ENVIRONMENTAL HEALTH DIVISION as soon aA " ' <br /> It is available and at the same time it Is provided to nrr or my representative. <br /> Nature of Service Req�rest: — _ <br /> P q L==a <br /> Date <br /> Assigned too In a..a,t � Employee p <br /> Date Service CorrYrleted --/ / __ Further Action Required: Y / N PROGRAM ELI:MENt �3 <br /> fee Amount Amount PaidDate of Pnynent Payment Tyiw Receipt M Check p Recvd By <br /> ACCT 1 - -� / UNI i CLK _—/ / <br />