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• �" SERVICE REQUEST .../ (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD} ID # INVOICE <br /> FACILITY NAME 1/ D �� 6/-- ��7/02F"P,5 BILLING PARTY YJ / <br /> SITE ADDRESS "' �/�0���/,Of <br /> CITY S�o��/P�n/ CA ZIP !)7 <br /> COIM)E /OPERATORI <br /> (�(7 BILLING PARTY / N <br /> DBA VO �(AcGG, S PHONE #1 (.2 05') 5'{Lq- LIS/� <br /> ADDRESS /O 3Lg x -`t PHONE #2 CL )�- <br /> / O 6 <br /> CITY L�/�/ ��// STATE C�' ZIP <br /> P APN # <br /> I Land Use Application #F <br /> ii 80S Dist Location Code <br /> CONTRACTOR and/or \\ /�/- / ��/ /J <br /> SERVICE REOUESTOR V/�YJ /?�IZ P�G ��J �L 7/`✓ �/7T/�(t7� � � <br /> BILLING PARTY Y /�-� <br /> DBA .,/tel /-//7CJ/(�G �`� ,,//n�('. PHONE #1 ( <br /> ) 162 - LTS- <br /> MAILING ADDRESS J/ /" ��G/�% Ir �+ FAX ## (2-&�/) 3.6 <br /> CITY `��� / STATE If • ZIP / S z- / 0 <br /> Y°Ta`u IAN E1r3 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/vorgrojectt specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the party identified ag>,hq Lih "Y on <br /> Page 1 of this form. >AN JVaUjIN Gv ., <br /> PUBLIC HEALTH SERVI,(�'p( <br /> 1 also certify that I have prepared this application and that the work to be performed will be c16&V1RChbA*dp114@ MLWT4I'�V�SI <br /> JOAQUIN COUNTY Ordinance Codes and Standard S rat laws. <br /> APPLICANT'S SIGNATURE : r T <br /> Title: <br /> !/ �• Date: d000 5 J <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 /> Nature of Service Request: f� m Service Code (� <br /> Assigned to ' Employee # \l \J Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment T Receipt # Check # Recvd By <br /> 3 Q 96 <br /> REHS _/_/_ SUPV _/ /_ ALCT' /_/ UNIT CLK _/_/_ <br />