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SERVICE REOIIEST n ct. bed 8/23/43 <br /> FACILITY ID # jRECORD ID # INVOICE <br /> FACILITY NAME L 1W A BILLING PARTY Y / <br /> SITE ADDRESS W1 W L5 T CLCU iNJ rN 6 Z-ZgET <br /> LL-- <br /> 1--/ <br /> CITY TA4C v CA zip 9 5-37 � <br /> OWNER/OPERATORTIMI G r //L4 C�5/. BILLING PARTY / M <br /> DBA ,,II PHONE 41 C Z�) �S 3L - gelzZ ' <br /> ADDRESS SZ,f� T"Cy �/I/�' GT PHONE #2 C ) <br /> CITY 7/e�1�1/ STATE 6.-1 ZIP / Sj-7h/_ <br /> rAPN d Land Use Application # <br /> I DOS Dist Location Code <br /> CONTRACTOR and/or 333 <br /> SERVICE REOUESTOR il)2 r!,>,-/N� r/��/,7IhI1//l UAjlV�1'/IJCr,Ap[,�//S/�/iQ1C,C /✓C BILLING PARTY Y / N <br /> DBA �I'TT/1/ / !'/7'UL I1,6;eA 09 - PHONE #1 (Zoy ) k73 - 67TH' <br /> MAILING ADDRESS ! %6 � 7E- LL- bfre5i tl AJ,+x, FAX Z09 93? 5 19 <br /> CITYT�44/ STATE zip 91326' <br /> BILLISG ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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 farm. <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 a t rds, State and F rat laws <br /> C <br /> APPLICANT'S SIGNATURE <br /> c <br /> Title: Date- Z/ <br /> Zj <br /> Ll <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 �' .LO_SU,P� eC,E'. G) Service Code L- <br /> Assigned to 7� Employee # 0 <br /> (41 Date _I / <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check it Recvd By <br /> IC2 � � <br /> ACCT f I�/� / nL 'UNIT CLK <br /> i <br />