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SERVICE REQUEST • (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # 0 /-, INVOICE # n 353�3 <br /> FACILITY NAME pT� K,4N7-EG/4 BILLING PARTY Y / N <br /> SITE ADDRESS A"(0 3 W . L du /S E 4 y E N u E <br /> CITY p—i r7A.)7-4—: Ci CA ZIP 1?5-337 <br /> OWNER/OPERATOR B (O12EGYG�/I�-)G TLcHn�OC.DC�E-S InJ� BILLING PARTY / N <br /> DBA PHONE #1 (-20 <br /> ADDRESS a 4 0 3 W • L.du t,S E A-✓E , Q�^ PHONE #2 <br /> CITY l-'f +�McC <br /> -A STATE ITd ZIP 7J 337 <br /> APN # and Use Application # <br /> BOS Dist Location Code <br /> IF <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR IC7 f O �EG i GL/N&'" 7-LC-G1-tN0C-0Cw-t-SS .SNC.. BILLING PARTY 7y�x <br /> N <br /> DBA PHONE #1 Y�(oto <br /> MAILING ADDRESS oZ 'L 0 3 LA-) ' LdU (rr-C A c/ Q FAX # ( ) <br /> CITY lg4, ^j7'IEGA STATE G ZIP <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 /> 1 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 <br /> Title: <br /> Date: <br /> LIC HEALTH SERVICES <br /> `IVVIppe � ra:l�� 1a Leh¢ <br /> UTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, opera "6?OrY <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: /iJt�JJel�ol W.�S{C J r�t t7DDhcm-6w.- Service Code <br /> Assigned to 'OL ✓E( Employee # -32-1 Date 2• / / nl 7 <br /> Date Service Completed / 1 Further Action Required: Y / N PROGRAM ELEMENT ��• 2'� <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> �37V . 39 v. 415'7 e,Fr€�c� <br /> SUPV �/ / ACCT �0/ C/� /� UNIT CLK _/ / <br />