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SERVICE REQUEST (EH 00 61) Revised 8/22J3/93 <br /> FACILITY ID # /"f� RECORD =# ( L� INVOICE # 3 a r <br /> FACILITY NAME 4£0. T'Zv[ iC BILLING PARTY Y I <br /> SITE ADDRESS 31P33 DU` k C2€e k <br /> CITY ! TTVC-kCA ZIP <br /> OWNER/OPERATOR J A A bt v e BILLING PARTY Y / <br /> DBA I�� i�E TQ`sC (C PHONE #1 C143 <br /> ADDRESS PHONE 92 ( ) <br /> CITY STATE ZIP <br /> APN # 71Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or f <br /> SERVICE REQUESTOR -��N�� .Si:'� �Clpv`a'�VC "i `+: `1 BILLING PARTY Y / N <br /> DBA �E(Z- - rP-QC-K PHONE #1 ( ZcG� ) c/q3 - SD-5-e <br /> NAILING ADDRESS Z5 3$ W£ST L �` FAX # ( ) <br /> CITY �OG kTCIJ STATE C-A ZIP 9.5-2 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PMS/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 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 /> APPLICANT'S SIGNATURE <br /> Title: �G� {�ANtuR Date: 1a �7"r <br /> J <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 /> 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. <br /> Nature of Service Request: Service Code p <br /> / / 2 <br /> Assigned to _ Employee # � Date 10 � , <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RENS 11 c3 / SUPV / / ACCT T ?�/ '/ 7 / _ UNIT CLK �/ / <br />