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F I <br />FACILITY ID # RECORD ID # INVOICE # /J 'f0 � /A <br />SERVICE REQUEST % (EH 00 61) Revised 8/23/93 <br />FACILITY NAME H01 -1A)1 -CAJAI EXPRESS BILLING PARTY Y / N <br />SITE ADDRESS 16 .53,5– OCD VARIAN Rog,D y <br />CITY .LAiI+)eOA CA IIP 93-33 _ <br />p - I Z ✓ 1I <br />OWNER/OPERATOR <br />DBA <br />ADDRESS <br />BILLING PARTY Y / N <br />PHONE #1 ( ) - <br />PHONE #2 ( ) <br />CITY STATE ZIP <br />APN # P Land Use Application # <br />IBOS Dis[ Location Code <br />CONTRACTOR and/or T <br />SERVICE REOUESTOR \9 llfj:iAj OO L.S� ! NC' BILLING PARTY Y / N <br />DBA l OM W I (,LAP -0 t .LNC. PHONE #1 (020 <br />MAILING ADDRESS 28/0 Jr/f1-J {gV-61 l£ s4/IT: — 5-- FAX # ( -IV ? -:;Z-�C,6 5 <br />CI TY 31-0(?,A'-MNr STATE 447. ZIP 9.5-.1-03 <br />ray <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site,,elld/ot pS ct specific <br />PHS/END 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 a 9 199 <br />I also certify that 1 have prepared this application and that the work to be performed will be d9ngM1 in accordancewith ell SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Fed aL laws. tfV VI ` C'IL~ L._I„ SF'I,✓ICL:. <br />`�/ / RUNMEN7AL HEALTH <br />/'�, � � OIVISIUro <br />APPLICANT'S SIGNATURE / }2n � <br />Title: 461e{y Date: /�/d✓ 9 / i9� <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when appLicabLe, 1, the owner, operator or agent of sane, 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 />it is available and at the same time it is provided to me or my representative. < — A <br />Nature of Service Request: <br />Assigned to <br />Date Service Completed _/ / <br />Employee # <br />Further Action Required: Y / N <br />Service Code <br />Date <br />PROGRAM ELEMENT.S,1, 1, U/ 1 <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # • <br />Recvd By 41 <br />RENS !i / / -I SUPV / / ACCT �I/v/C� I UNIT CLK <br />e715 _, <br />