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-i.'. A-1-1956 02: 19PIl FROH 10 W,20180 P.02 <br /> SERVICE REQUEST (EH 00 bi) Revised 8/23/93 <br /> FACILITY ID M <br /> RECOFID IDM INVOICE # <br /> FACILITY NAME �r�S.h`Bl�L.0 "��/�� BILLING PARTY Y / <br /> SITE ADDRESSX3/3 Ci 4111 -s W�� '- <br /> CITY CA ZIP ©S/ <br /> OWNER/OPERAIOR ( �f 81LLING PARTY Y / N <br /> PHONE #1 <br /> D 3 T <br /> AVURFSS ISO ��io�k 7 --- L/ PHONE <br /> 02 <br /> CITY 6:9R 64f 61f STATE .L�.f! ZIP 9%•�7�7 —_._ <br /> --.Ap�— T Land Use Application # <br /> BOS Dist location Cock <br /> CONIRAC70R and/or _ s� <br /> SERVICE REQUESTOR X/Z7 e o ow—z.PB�t//TJ.ha/�d'� BiLUNG PARTY Y / N <br /> DBA PHONE #1 ( ) <br /> MAILING ADDRESS 31149 349A66 FAX # ( ) <br /> CITY ���=�� — STATE �— ZIP Frgr2L <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page I 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 all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANTT'/''JS��SIGNATURE <br /> Title:_(LeC�nAgAl, lYldii/LO.a Date: <br /> AUTHOR�IATIIONONTO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of sank, 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. (�(�p <br /> Nature of Service Request: Service Code / <br /> Assigned to ( �� �/�[ S Employee M DdD 6 Date.—/'.'�" y4p <br /> Date Service Completed /_,..1 J� Further Action Required: Y /QM PROGRAM ELEMENT /��7a A <br /> L�3 <br /> mount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> °% a3 � yy <br /> I / errr / / 7 / UNIT CI.K <br />