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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD [D # f''` .� y, INVOICE # <br /> FACILITY NAME JouthlanGl 7-eleven �e# 1411 BILLING PARTY Y- / <br /> �f <br /> SITE ADDRESS _2725 Gauv4ry Club C3oulev9rLJ <br /> CITY `J'fbGk1'1D�,1_,,( / l CA zip IJ�4 <br /> OWNER/OPERATOR �DJV1 12V-d �{C.�0r0Zr ,11 f�\ BILLING PARTY Y / N <br /> DBA /, T- 4� 1- r-ra �JMFxe * 11"'F�II7 '/ PHONE #1 (91(o ) L'W - aZ(O5 <br /> ADDRESS <br /> `7-33'1 &Did I aC.Ou�(^� Way , W TOA PHONE #2 (91& )�GJ� - 7711 <br /> CITY Gold Rider' STATE LA zip X15(070 <br /> APN # p Land Use Application # <br /> IBOS Dist Location Code <br /> SERVICE REQUESTOR (6�y1 Gr OE! (214n: ' 2 &i3nin0BILLING PARTY Y /® <br /> DBA 64eM ?Or 5oL*IiJa. PHONE #1 (g1Co )(o4&- 4 !03 <br /> MAILING ADDRESS (a5c Howe, Avenue , 4504 C, �7FAAGX # (Al(, )&4Co - !o? <br /> Qq <br /> CITY Sacrameni�c, STATE GA zip _I SJ <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project spec'fic <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 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 /> APR 2 01998 <br /> APPLICANT'S SIGNATURE <br /> SAN JC!AQLHf1 <br /> Title: GOY 11On Date:_ !/ J FUOtJC Ii=,4L1 r6 SLRV'f.ES <br /> E1J01FTCAat✓rENTAL HFA0H DIVISION <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 infonma tion 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: l� Service Code b <br /> Assigned to 1) pl Employee # 9 �� Date <br /> Date Service Completed _ / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment PaymentTypeReceipt # Check # Recvd By <br /> REHS I / Z_ SUPY ACCT / — /_A uNi( CI_y, <br /> __i-- <br />