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�. SERVICE REQUEST (SERVREG) Revised B/23/93 <br />fAf.IUTY IDB RECORD ib / INVOICE B <br />rACILITY NAME _SRa L-enA-Pi POppwr __ HILL ANO PARTY / N <br />SITE ADDRESS c 3�0 1 S, Coy wAiv r6b. <br />CITY TPAC`1 CA ZIP (-,/ 6 _ <br />(MFR/OPERATOR SUP1I-PPA-N) PZOPPYVI BILLING PARTY I O / N <br />DBA SUAL ,eg,07L) 1?Z0PP' )U1f/J PHONE •1 (�)��J - a <br />Z'C-) <br />S . <br />ADDRESS , )90/ S IC <br />cl-wls"Anf O. PHOME A'2 ( ) - <br />CITY T(Zfi1L/ STATE (1 21P /4)5 7h <br />APN*s Ir Land Use Application N 11 <br />BOS Dist Location Code <br />CONTRACTOR rind/or A <br />SERVICE REGUESTOR ALL EAJU/ 1)A)AAeA PTAt, A)e � �/T�=�-/- � BILLING PARTY Y / <br />DeA @qV[-�7 PHONE I1 ( S! 0 ) <br />- \ 620 X32 -- <br />MAILINO ADDRESS /7�k(/ C n(i)A, C�nN L0 ) � 5 / FAX A ( 576 EE Z6 - - <br />c <br />CITY xrniV rCAN 0/U STATE C_ IIP <br />PILLING ACKMONLEDGEMENT: I, the tiderslgned owner, operator or agent of some, acknowledge that all alto and/or project specific <br />PHS/END hourly charges associated with this facility or activity will be billed to the party Identif led as the BILLING PARTY on <br />Paqe 1 of this form. <br />I nlso certify that 1 have prepared this application and that the work to be performed will be done In accordance with sit SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br />APPLICANT'S SIGNATURE <br />Date: <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the over, operator or agent of some, of <br />the property located at the above site address hereby authorize the release of any and all results, geotechnical date 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± 0 ' service Code <br />Assigned to <br />Employee / <br />Date <br />Date Service Completed _1_/_ Further Action Required: T / N I PROGRAM ELEMENT <br />tee Amount Amount Paid Date of Payment Payment TypeReceipt Check / Recvd By <br />SUPV _/_/_ ACCT_/_/_ UNIT CLIC _/_/_ <br />