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I L-IO1-19.3/ 3; 11" +14t . . P. 3 <br /> . SERVICE Raoul$? (EN 00 61) Revised 8/23/93 <br /> FACILITY ID R RECORD IV 6 �(� (%)� INVOICE 0 <br /> FACILITY NAME �JC / t?Y'� BILLING PARTY t / s/ <br /> Real <br /> SITE ADDRESS �,t. e'�w� �� lrC✓T7. �/ <br /> CITY 57bC/+Cye // KOA� ZIP 43 <br /> OPERATOR It BILLING DARTT ('moi / N <br /> DBA N/rI �bsa {tea j 7�( MORE :t ( I c <br /> s <br /> ADDCA- 9sz REs 13�a {tel /1 r2 <br /> Cl $FAYE <br /> zip <br /> We a --- -- use Application R - - - ----- <br /> BGS Dist I tion [ode <br /> CONTRACTOR "/or <br /> SERVICE REOUESTOR 1 65 ) BILLING PARTY <br /> DBA I i I( f//j PWCMF. TrI <br /> NAiLINC ADDRESS lilUS 1Jb2 { /.�5, (�4kS 14,x- FAX r <br /> CITY _ !2"7i✓f STATE C ZIP 2sZ6S <br /> BILLING ACKNOWLEDGEMENT: 1, the urdersignad owner, operator or agent of same, ocknculedge that •IL site and/or project speclf lc <br /> PHS/END hourly charges associated with this facility or activity will be tabled to the party Identified as the BILLING PARTY on <br /> Page 1 W this form. <br /> 1 also certify that I hove prepared this application and that the work to be performed wiLl be done in accordance FLfI1tE <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and ftderat laws- <br /> APPLICANT'S SIGNATURE <br /> aws-APPLICANT'SSIGNATURRE V�/r�.l Y'L/LJ`1 Q--.. DFC 17 <br /> Title: /s-Tf-✓Ltd - i}�T Dote• FuaVdo aur ? ,. <br /> -T� VIR0AfWHH&gL/TH g'RUyNTY <br /> AUTNOIIZATION TO RELEASE IHFORMATION1 In addition to the shore, when applicable, 1, the owner, operator or agent aF,��SAJ.Tgr01Vs)0N <br /> the property focated at the above Rite address hereby suthcrite the release of ray and all results, geotechnical data and/or <br /> ernirvmenbl/sat assessment infcreation to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the sane tine it Is provided to me or my representative. <br /> Nature of Service Rest: - Service Code 4 <br /> A,sipned to l.2 f "1 i Q,hr, 1 �a �J EaErlay.. 0 �— Date <br /> 46-41// 1GL. <br /> Date Service Coepleted _/ / Further Action Rewired: r , / N PROGRAM ELEMENT <br /> Fee Amasrt An t Paid pate of Payment Payment Type Receipt A Check B Roeyd By <br /> supv Am --- ��_/_ UNIT CLk <br /> ��`i6 <br />