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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br />FACILITY ID # <br />RECORD ID # cJ INVOICE # <br />I— <br />FACILITY NAME Q <br />l�tAMII�j,�,,-,�PI-MPo T -y ^ BILLING PARTY Y / <br />SITE ADDRESS 38600 C.�K�J4L Oou,[)w 1w <br />CITY Tr2AC CA ZIP <br />OWNER/OPERATOR C�fT6Ad' A -WAX INC— BILLINGPARRTY 'y / N <br />DBA tt 11 PHONE #1 (Zt,/ )Ste- %r3 <br />ADDRESS 9Z0 bwxpAA.j�- I)& - ��t PHONE 92 (�) otj -b7$ <br />CITY MO') 'L T -o STATE C4 ZIP �`9 ?7 p <br />pPN # <br />CONTRACTOR and/or —Sr" <br />SERVICE REQUESTOR 7 <br />11 <br />DBA <br />Use Application # _ <br />MAILING ADDRESS 1217 7, -71 ti J+� <br />CITY Mol�srt> STATE r1 ZIP <br />BOS Dist Location Code <br />BILLING PARTY Y, / IN <br />PHONE #1 <br />FAX # (2en ) -Sy -06-(53 <br />11 2, St <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or 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 />1 also certify that I have prep red this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Code and Standards, State and Federal laws. PAYMENT <br />C RECEIVED <br />APPLICANT'S SIGNATURE <br />Title: 1� AA+ SO -4 c o Date: SEP 15 1997 <br />A <br />SAN <br />1 JOAO�UINtCUUNTY <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when,applicabl e, 1, the owner, oceViliONk TAI MEp�LTBH D�VRIStONf <br />the property located at the above site address hereby authorize the release of any and all results, geotec nkat data a 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 <br />Request: . 1 I a Oi WA CrQ&II G 1A I Service Code ✓ J `fes _ <br />Assigned to I✓ Dy-� N - �— • Employee # 1 9 �� Date <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br />Amount <br />Amount Paid <br />Date off Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />1Fee <br />19,2z/ <br />RENS I'�/,�S I SUPV I -- /—/— I ACCT I _//__ _ I UNIT CLK I _/_/_ <br />