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now <br /> SERi/Im REaIESi fEH lm 67;• Revised 8/23/93 <br /> FACILITY iD # IJ RECOL <br /> RD ID ! � ` c �I INVOICE ! <br /> FACILITY NAME 0�k_TUM i�F �@V� diwlelIy�AKC P \ 'c1U ITS BILLING PARTY Y / N <br /> SITE ADDRESS c� )�Ik�O Qoad • _ <br /> CITY c4nt "o V\ CP ZIP. Q,Z�-Z L <br /> CYNER/OPERATOR S BILLING PARTY Y I /N� <br /> DBA (n1�Pl�a PHCNE 91 <br /> ADDRESS -l. Vk 17l Vel ((11 PHHO.NEI 92 <br /> CITY C f STATE _CLZIP �15� l 1 <br /> rAPN 3 Land Use Applicatfi / <br /> EOS Dist Lo®t4an code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR �M 1h �hA\tA f'_ �P-+r{ _.�Y�C- BILuNG(PARTY <br /> Y .-�/ H� <br /> DBA '� VN'e PHONE In (.-I <br /> MAILING ADDRESS `� MAk e kC-e Dk LJ a FAX x ( ) 3'1z- - L M <br /> CITY W S���r11p STATE � ZIP <br /> BILLING ACKNOWLEDGEMENT. 1, the undersigned owner, Operator er agent Of same, ackrowLedge that all site end/or Project Specific <br /> PNS/EHO hourly charges associated with this favi City or activity wi LL be billed to the party identified as the BILLING PARTY on <br /> Page t of this form. PAYMENT�a <br /> I also ns certify that I have prepared this application and that the work to be performed will be dairf S9tlddei"FvQh all SAN <br /> aoAQU1N COUNTY Ordinance and S and Faderal laws. �Ii.IN 2 21(X1(! <br /> APPLICANT S SIGNATURE h ��« <br /> -i�p.ACNPd 'r:VIF IOh <br /> Tit le= lltil J Data' <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of score, of <br /> the property located at the above site address hereby authorize the release of arty and alt rewtts, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAadiN axNrT PUBLIC MALIN SERVICES ENVIROMMUTAL HEALTH DIVISICN as soon as <br /> it is available and at the same time it is provided to we or my representative, <br /> wat of Service RenFsst: 7 Asa^ �� Sa'"ice Cade 012Assigned to L Employee ! I > Date _J_J <br /> Date Service Completed /_� FLA Cher Action Required.' T / M PRa7AM ELIMM <br /> Fee AmaAnt Amatnt Paid Data Of Paymmt Payment Type Receipt 0 Check ! Recvd By <br /> RENS �.u.J�� StAr/ J_/— ACCT J_/ NrLT�CLIC � /— <br />