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SERVICE REQUEST (EH 00 61)Revised 8/23/93 <br />FACILITY 10 #RECORD 10 #INVOICE # <br />Date __I /_ <br />X'FACILITY NAME?~V4::z;l2v<1/r'lt/4 <br />1\SITE ADDRESS~#/YJ1tt!I/JZ):$A <br />CIT~~CA~~D~R~ <br />A.OUNER/OPERATOR ~/-P~K/d4 a <br />DBA;a.7Y£-z74d~K/dq &. <br />ADDRESS~#A14&~~.s/f &- <br />CI~K7;;.I STATE M <br />[APN #$;if/I [Land Use Appl icat ion # <br />CONTRACTOR and/or ~ <br />SERVICE REQUESTOR __--=-_ <br />DBA ~~~f~)1--,----------------------------- <br />MAILING ADDRESS ~C;.:.-_,.:.14__,_ <br />CITY 5 __11-'---_ <br />~=B=IL=L=I=N=G=P=A=RT=Y=L0 /N <br />ZIP C)..S"~S- <br />BILLING PARTY <br />PHONE #1 <br />PHONE #2 <>_ <br />ZIP _q~.6::......:2LJ==_....:_.S _ <br />II!:::::==BOS=DiS===t1====1 Lo=cati=onC=ode ==1 = <br />BILLING PARTY Y 1 N <br />PHONE #1 <>_ <br />FAX #<>_ <br />STATE _ZIP _ <br />BILLING ACKN~EDGEMENT:I,the undersigned owner,operator or agent of same,acknowledge that all site andlor 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. <br />I also certify that I have prepared this pplication and that the work to be per.formed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance C s Sta r ,State and Federal laws. <br />~'APPLICANT'S SIGNATURE .~~~~~~~----------------~-~------~~~~~~~-- <br />~T itle:_....>.~...::........:.:::....:::~.•..•.••z&j..::..IL-,""""Loo=....----------Date:-<----.:.._-'---;:.;..,;..:.=-.....:.=c...:..:..-_ <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 />it is available and at the same time it is provided to me or my representative. <br />I I Service Code .s "',2.:2-. <br />I <br />Date Service Carpleted __/1 _Further Action Required:Y /N IPROGRAM ELEMENT fez C)/ <br />Amount Paid Receipt # <br />-1_1-1 <br />Fee Amount Check #Recvd By <br />I <br />__1__1__1 UNIT ctx