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' FACILITY ID # I <br />FACILITY NAME <br />SITE ADDRESS <br />CITY <br />OWNER/OPERATOR <br />DBA <br />ADDRESS <br />CITY <br />ARM # <br />CONTRACTOR and/or ��- <br />SERVICE REDUESTOR -J I <br />DBA <br />RECORD IO # <br />Y <br />SERVICE REQUEST <br />INVOICE # <br />Revised <br />CA Z Ip <br />F—B ILLING PARTY I =W <br />PHONE #1�I� <br />STATE <br />Lard Use Application # _ <br />PHONE #2 ( ) <br />ZIP _ <br />BOS Dist Location Code <br />BILLING PARTY <br />/fin_ �Y PHONE #1 ('_t>cT� )3t'�Q�_ <br />MAILING ADDRESS _/ /'ti' 2,1Z Y -3JF 2 FAX # (2c / ) 4 / <br />CITY fl ' it STATE 2IP <br />CIY I <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that e*[Vi=e ojeet specific <br />PNS/END hourly charges associated with this facility or activity will be billed to the party idem �e3 LING PARTY on <br />Page 1 of this form. F E B 17 <br />SAN 1Ud/ <br />I also certify that I have prepared t application and that the work to be performed will iR(Jpgrdence with all SAN <br />JOAOl11N COUNTY ordinance Codes e t rdsrStete Wy Federagl laws. ENVIRONMEN AlFIaA 'naiJiglON <br />APPLICANT'S <br />Tit( <br />AUTHOR17AI10H TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 />envirormiental/site assessment information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />._ _...w .. .k- — .;— it ;a nrnv;r4.d to me or aw reoresentative. <br />Nature of Service Regwest: <br />Assigned to L., i (' ) Errployee # _6nf.__ <br />Date Service Coapteted _/ <br />Further Action Required: Y / N <br />Service Cod U 3 <br />Date <br />PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />67 <br />3 , `) <br />-2- <br />Oj� <br />RENS I _/_/_ I SUPV I <br />A <br />