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SERVICE REQUEST r. (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # T RECORD ID # 7 INVOICE # <br /> l- gl <br /> FACILITY NAME lt — -AMP- 141L-f,7 <br /> ,/ `. BILLING PARTY Y <br /> W <br /> SITE ADDRESS 4 3 1 I �1&&q- 141L-f: T"Tom-,�d p <br /> CITY fjN k-4-UH\ , ,pl,A� CA Z <br /> OWNER/OPERATOR' �(�{htL-�.-- BILLING PARTY p Y / <br /> DBA PHONE #1 (�)/S/ - <br /> ADDRESS PHONE #2 C ) <br /> CITY STATE ZIP <br /> ApN # p Land Use Application # <br /> ISOS Dist Location Code <br /> CONTRACT nd/or <br /> ERVICE REOUESTOR- C66-M((4-S2i1Cf-. CPI En- C© fl y BILLING PARTY. Yo�N <br /> DBA �J 'p PHONE #1 (� �L <br /> I -SS3.3 <br /> MAILING ADDRESS e7� D 1,bL71L �+I FAX # ( ) -403 / <br /> CITY �'9'r1�T'!r.< STATE--v11 ZIP . zA 1 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of sane, acknowledge that all site and/or project specific <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 th application and that the work to be performed will be done in accordance with.all SAN <br /> JOAQUIN COUNTY Ordinanceds State and Federal laws. �FEE' .1 : D <br /> APPLICANT'S SIGNATURE i FEB <br /> o G 1 M5 <br /> SAN JOAQUIN COUNI Y <br /> Date: f—z--z--�S / PUBLIC HEALTH SF%,VICES <br /> Title: <br /> LN'v'IF h4�f; <br /> AUTHORIZATION 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 /> environnental/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 representati e... r LE <br /> Nature of Service Request: .fr�/yn1 , Service Code <br /> Assigned to V V Employee # h q- R Date _ - L 2, /S) <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> '� ! V <br /> SUPV I- _/ /_ ACCT / / ✓' UNIT CLK _/_/_ <br />