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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # log,60 v <br /> FACILITY NAME F"6 l 17Y 97-e 0 BILLING PARTY YV / w <br /> SITE ADDRESS S79D NV. /Y WY 12— <br /> CITY <br /> ZCITY Lod; / CA ZIP 9S�9O <br /> OWNE OPERATOR J O"J 7-P Ng //dci tin BILLING PPAARTTYY /YJ / Np <br /> DBA 5a ry,a PHONE #1 (�) /- <br /> ADDRESS _ y� 46 /5/l i2flel l �� p PHONE #2 (20 > 402-- 5-/72- <br /> CITY _ /T(/.rYLPACY STATE 6�4 ZIP <br /> �APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR)and/or / <br /> SERVICE REQUESTOR S-�f 12 PV, /42 <br /> C/ BILLING PARTY Y / <br /> DBA F/ J/n wr,- C[�/I 5trI CT7,)0 PHONE #1C9/6 7,- /7RY <br /> MAILING ADDRESS por`fFAX # <�pL61 ' T '�)1 <br /> �C�.- ll <br /> CITY J&IeST StlLrf myon T1D STATE e�'W ZIP I F,I <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowte a that all sit �I`•1�.00rr project specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the part Wr2 fSkd%%e BILLING PARTY on <br /> Page 1 of this form. <br /> ENVIRONMENTALIT/SERVICES <br /> LT <br /> I also certify that 1 have prepared this application and that the work to be performed will one in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codecs and Standards, State and Federal laws. ��1- Z ❑Ai j /f�J` -� (I,��L.1• <br /> APPLICANT'S SIGNATURE :�,C/ �4�v�- G, /?L (��J�i7��n,yi�lrwLr/1-5 IC7J`7?JN —1,;. v` ✓I <br /> Title: V —777 Date: -S--.23 —'�79 (�F�Aq lFCEIVF-D <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or eg ; PUP bi6 <br /> the property located at the above site address hereby authorize the release of any and all results, geotecftnieaUdAQ4%I@f>i!/ZF,N1Y <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALYA4NI!;"L TsHs�6FVWCES <br /> it is available and at the same time it is provided to me or my representative. cNVIHU IVENTAL HEALTH DIVISION <br /> Nature of Se rvi a Request: Service Code <br /> ,(/lp signed to Employee # Date f_/ 7 't <br /> Date Servi a Completed / / Further Action Required: Y / N PROGRAM ELEMENT 2 Z <br /> Fe Amount Pai Date of Payment Payment Type Receipt # Check # Recv By J <br /> IT <br /> /��S.cn say �6s <br /> RE HS Clv/ / SUPV —/ /_ ACCT / / UNIT CLK <br /> yr <br />