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12-20-1995 09:09AM FROM TO 19163970902 P.03 <br /> SERVICE REQUEST (EH DD '61) Rgvised 8/23/93 <br /> F�CtLITY ID 9 RECORD 10 INVOICE k -• <br /> --r 1 f ( /' n /l <br /> -::FACILITY NAHE �JVu3�A�c l'vT�eh -1-Sand t'Ii�e Ia —C��i��� r¢� llMeh BILLING PARTY Y / M <br /> SITE ADDRESSyk�er.►!ZS�R '1JDArsk. I►+.:Iz was+ XT..r4v$lv�.� Ii,.�'t$� c� I�� •,• �; <br /> CITY Rpfl,�x.E <br /> C' yti:{eg �or�� o -�rtLS[ CA ZIP <br /> 6 <br /> " HER/OPERATOR (�t1�b�K9��Ce�-�nauy ��Ca�. rhFA Uho�yl� BILLING PARTY T / N <br /> i <br /> :. <br /> DBA PHONE :1 <br /> Ale` <br /> S ADDRESS �.d• jc�)C �O / FHONE �2 <br /> „,le` <br /> CITY C04I61A0. STATE _ Z1F `3 Z l C <br /> "JimAPN 0 Lend Use Application V <br /> I�G 0SOS Dist Location Code <br /> �CDWACTOR and/or <br /> iERVICE REGUESTOR + Moot'e— BILLING PARTY <br /> DBA j FxCNE f±l ( ) �i`$ - 4800 <br /> ILING ADDRESS l F015o, 61v� FA.X ( Rl6 ) 3b otsoz <br /> #L% CITY STATE ZIP °t 7 Z C <br /> i 4iLLWO ACKNOwu[)GEHEO, f; .the undersigned owner, operator or ,-gent of same, acknowAdge that all site and/or project specific <br /> >L, .;:blLf/END hourly eharses associated pith this facilitf cr activity will be billed to the party isentified as the BILLING PARTY on <br /> , '.�+6pe of this fDem. <br /> ,1 !Iso certify that ! :have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> 11*00LItANT'S <br /> Aki11liq COUNTY Ordinarice Codes and Standards, State and Federal lass. <br /> SIGNAIURE�: o„ (� <br /> Date:_ <br /> x+'..11•.•.. C <br /> ' :AUTHORIZATION TO RELEASE INFCXMATICN in addition to the above, :hen spplica• le, 1, the cwner, operator or agent of sine, of <br /> 'tile property Located at the abo-.e site adiress hereby authorize the release cf any ar•i aLL results, geotechnical date and/or <br /> rY onviromwntal/site sssessrent inforrraticn to SAN JOAQWX COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIO a% soon e$, <br /> Tit is available and at the same tuna It is provided to me or mf representative. � ( /& � <br /> �'•. Miture of service RegJast: Ser.ice Code J 0 C) <br /> 'Assigned to /Y/` ' Ecplcfee >* I14 <br /> Date <br /> j Date Service Ccnpleied / / Further Action Recuire-�: T / N PRCCRAH ELEMENT <br /> Ni Amount A=unt Paid Date of Payvtint Pa-7mtnt Iy;n Receipt Check.: Recvd By. <br /> J,t` RENS r��/ SUPV _/_� ACCT «/ �' �� 0;IT :LK _/_/ <br />