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I <br /> �... `�SERVICE REQUEST (Ell 00 61) Revised 8/23/93 <br /> FACILITY ID # I RECORD'ID # �D�/� I INVOICE # <br /> FACILITY NAME' <br /> i 'Cj"� z �'f �I'O(,/IC70r1 1 AA3KI`5 BILLING PARTY Y / N <br /> —__ <br /> SITE ADDRESS C, 1 J <br /> CITY V1U m,"n I/ CA ZIP 5aA� <br /> OWNER/OPERATOR �) /1 (1 81LLING PARTY <br /> ( \ PHONE #1 ( 201 ) Ibr- (T y Irl <br /> DBA <br /> ADDRESS PHONE #2 ( ) <br /> CITY 5.1-.�<K�o� STATE Cod" ZIP �15d �a <br /> �APO # F Land Use Application # — <br /> IDOS Dist Location Code <br /> CONTRACTOR m.1/or <br /> SERVICE REOIIESTOR J(iAn UQ GPa \d1 V 1./.FJnmel� I BILLING <br /> DBA PA,R,�T�Y <br /> ( PHONE #1 (61 rx\ <br /> MAILING ADDRESS CC` ���/ Oi/� �w/ / ! //" /� FAX # (Z-OA ) 9GL, 0700 <br /> CITY S4oC K4QV--% STATE S1 ZIP 95dP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of sane, acknowledge that all site and/or project specific <br /> PIIS/END 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 1 have prepared this application end that tire work to be performed will be done in acc44dpp4M Eth all SAN <br /> JOAOUIN COUNTY Ordinance Codes Standards, State and Federal laws. 1IR'"'/EA�YICWAT <br /> APPLICANT'S SIGNATURE : � L � AUG 1 7 <br /> Title: 5�10 FP CP O to Date: 1) l — <br /> SAN JOAOUIN COUNTY <br /> PUBLIC HE <br /> LTH ERVICES <br /> AUTHORIZATION 10 RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, oper@A91p61VM�fNA ERV�ICES 7N <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> enviromrental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It Is available and at the sane time it provided to or Aorrary�representative. <br /> Nature of Service RR..egresst: 1 LL J �p�"� " Service C <br /> Assigned to 4t / / 7! F� ( LIQ S Employee # �_� Dote $/�/�1'�rI <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT 2h 72 In Y� <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> UNIT CLK <br /> RENS ��/�_/ r SUPv }r„r,/_/_— ACCT / // __/ /_ <br />