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0 SERVICE REQUEST • (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # O V O O <br /> FACILITY NAME �,EC,'- C on1 l�✓ GO d,�9 6r)#Z BILLING PARTY Y <br /> SITE ADDRESS d_5/ )4-1 <br /> CITY C.�Q CA ZIP �SoZT� <br /> OWNE /OP�TOR �E�, TA CD..�Ti n � �o�oOlo BILLING PARTYY / N <br /> DBA f� �^ PHONE #1 <br /> ADDRESS r c, O � `� PHONE #2 ( ) <br /> CITY 7--Z)CfG—f--o STATE GA ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code G}Ct <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR ��LT� Go�7f1 �� - Gobi' BILLING PARTY Y /ON <br /> DBA PHONE #1 <br /> MAILING ADDRESS / J FAX # ( ) <br /> CITY J 1 "�i���/y STATE ZIP (:F5-;" <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. PA!.041Z `r <br /> I also certify that I have prepared this application and that the work to be performed will be done in adance•with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. JUN 7 `bSb <br /> APPLICANT'S SIGNATURE SAN J(,r-,O I N(�-�°'ii,j , <br /> `3ERV10E <br /> Title: Date: ENVIRONMENTAL HEALTH DIVI&()), <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 /> k,,it is available and at the same time it is provided to me or my representative. <br /> TOP <br /> of Service Request: /J So If a WaS fr FC /711��(Cc��Z i. 1�� Service Code �as` /ed to (� C7( f✓Cr✓�.- Employee # 3 Z/ Date cP /ervice Completed � /�/ �� Further Action Required: Y /(:IN PROGRAM ELEMENT � •`-7 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 3�o• o-z� ago . fns l0F-771,� Cfifc� 0 1'3 7 - C� <br /> RENS / 'I / SUPV l / ACCT UNIT CLK _/ / <br />