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SERVICE REQUEST (Eli 00 61) Revised 8/23/93 <br /> dILITY ID a RECORD IAN INVOICE E , <br /> =J <br /> NAME �r�� J1,�SQ� ��C BILLimr. PARTY Y / H <br /> ITE ADDRESS R3 ``1 Q <br /> _ CITY M�.+a��t-0.'> Y '_ CAS Z1P , <br /> R/OPERATOR ^. �-► " „� r F BILLING PARTY Y / <br /> DBA - .� _,r�; PRONE 91 6 <br /> ADDRESS t�ac ' PHONE~02 ( ) <br /> , <br /> CITY bt A - STATE ,L� ZIP <br /> APH'E Land Use Apptication M <br /> BOS Dist Location Code <br /> RACTOR and/or <br /> ICE REQUESTOR '� - r BILLING PARTY Y /G pM <br /> DBA PHOkE #1 (1v f-)���„' ! 1� <br />;NG ADDRESS o •t"1 4O a FAX ( �) y�o - <br /> �`• _ CITY ` � STATE > 2[P sl W ] <br /> LI ACKNOWLEDGEMENT. I, the undersigned owner, operator or agent of same, acknowledge that alt site and/or project specific <br />(ERD hourly charges associated with this facility or activity witt,be bitted to the party Identified as the BILLING PARTY on <br /> e 1 of this form. <br />(so certify that I have prepared this apptication and that the work tq 4e perfgrmed wilt be done in accordance with all SAM <br /> QUIN COUNTY Ordinance Codes and standards, state wA Fadarat laws t - ' <br /> LICANTOS SIGNATURE : <br /> J r <br /> f e- -1 to Pow _ <br /> HORIZATION TO RELEASES IHFUMTION: In 401tign tq the above, when appl.kobta,✓I, the owner, operator or agent of same, of <br /> property located at the above site aWr4se hereby aNthori:e the retesse of any and pit resutts, Geotechnical date and/or <br /> ironmtntat/site assessment Informtion to SAN 4OAQUiN COUNTY PUBLIC HBALTN SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> Is avaltable and at the same ttmw It Is Provided to me or as repro entstive. <br /> azure of service Requests service Code <br /> ssigned to Employes G _' , Date �J / <br /> 1J 5 <br /> ate Service Completed / f__-_-„� Further Action Required: Y / N n PROGRAM ELEMENT <br /> Amount Amount Paid Date of Payment PayW% Type Reasipt p Check ii, Rscvd By <br /> 1 , <br /> , r <br /> miaMom <br /> ACCT ' ,J� / UH I T CW <br /> ..._ _�. <br /> y r <br /> i <br />