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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # <br /> RECORD ID # _ �/Q INVOICE # <br /> Z/ <br /> FACILITY LUNE 11 <<- �+ (2- ` w��� „� BIILIUG PARTY Y / N <br /> SITE ADDRESS Ed <br /> CITY S4,nr. I CA ZIP < J^ <br /> OWNER/OPERATOR (��N� <br /> PHONE #1 <br /> ADDRESST,[� �j < PHONE #2 (� ) <br /> CITY ) at�L/"rhy STATE �� ZIP 7 J^2 Q <br /> 0 / <br /> APN # p Land Use AppLicatl on # <br /> IBOS Dis[ Location Code <br /> CONTRACTOR and/or () <br /> SERVICE REOUESTOR 1`I Cy-� ��� 1`F/ "1 wy BILLING PARTY / N <br /> DBA 1�-{1��� f /� S Y� ��J PHONE #1 <br /> b C 7 <br /> MAILING ADDRESS // s� 5! / 0 V > FAX # ( ) <br /> CITY = -�' 'y G n L_ STATE �_ ZIP �S r/ 3 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknoWtedge that all site and/or project specific <br /> PHS/END hourly charges associated with this facility or activity will ce billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance-w P.etu'ak.L-:SAN <br /> JOAQUIN COUNTY Ordinance Codes St rds, St to and Federal Laws. <br /> APPLICANT'S SIGNATURE <br /> Title: lDate: 3 -3—/O SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> NVInONMENTAL HEALTH DIVISION <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicabLe, I, 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 /> envirorvental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL WEALTH DIVISION as soon as <br /> it is available and at the sane time it is provided to me or my representative. <br /> I <br /> Nature of Service Request: jj�/' , Service Code 10 3 <br /> LLO/L BYO" //'Xn�l'Xdi�_6 la ff # n �- r. <br /> Assigned to v t�� mp Y ---r ' �y 1�'� ` _-�� Date <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT 3 n <br /> EFee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Racvd By <br /> �3 tul 1!191 Li� <br /> RENS / / SUPVL. /_� ACCs "NIT CLK <br /> � —/—/— . <br />