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r %- ": <br />FACILITY ID # RECORD ID # - INVOICE # I 6� R C/O <br />SERVICE REQUEST <br />(EH 00 61) Revised 8/23/93 <br />FACILITY NAME HOUDAY L/NN EXPA LLA -5 BILLING PARTY Y / N <br />SITE ADDRESS 16 88 S OCD P,9A/ d ✓ 12CA, 1) I. <br />CITY .LAil+4010 CA ZIP 9•s�i3 i <br />�s�— f z3Ll <br />OWNER/OPERATOR N <br />DBA <br />ADDRESS <br />CITY <br />STATE ZIP <br />BILLING PARTY Y / <br />PHONE #1 ( ) <br />PHONE #2 ( ) <br />APN # Land Use Application # <br />BOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR \ Q / WHAO O L.S. TNe BILLING PARTY Y / N <br />DBA I .qOM W I ILAP-1D I LNC PHONE #1 (e209)�_- 7zbl'r <br />MAILING ADDRESS IPJ/O FI.E LrD 79V671UL,(E S/!/% --5 FAX # ( 0 ). 945 - :7-,c,,69 <br />CITY 310CY-MA-J, STATE 04. ZIP 9,S,;L-0.3 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site., . rfior'4 4 ect 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. NOV — 9 199 <br />I also certify that 1 have prepared this application and that the cork to be performed will be dope, 9'atdbrdance .With alt SAN <br />"CJ L ;L, hL,r,Lir <br />JOAQUIN COUNTY Ordinance Codes and Standards, <br />//State <br />anand Fed at laws.� nEa=NVIRONMENTAL SF �LrH IVI�D1Vj <br />s!on' <br />APPLICANT'S SIGNATURE �•w�.,., <br />Title: A' /t'1� Date: Nd✓ 9 Z ?95� <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 />envirouental/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. dl _ A <br />Nature of Service Request: <br />Assigned to <br />Date Service Completed _/ / <br />Employee # ii : T <br />Further Action Required: Y / N <br />Service Code <br />Date <br />PROGRAM ELEMENT SI�iU�i <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />i <br />II / <br />% <br />/ <br />,! J <br />UNIT CLK <br />REHS <br />! / <br />/ <br />f, <br />I SUPV <br />/ <br />/ <br />ACCT <br />II / <br />% <br />/ <br />,! J <br />UNIT CLK <br />.> e7 -� <br />