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F 9 - - <br /> SERVICE RMST (El 00 61) Revised 3IZ3193 <br /> FACILITY 1R 1 <br /> RECORD ID p U r ) G / 1NVDICE p <br /> FACILITY VANE fC✓LW(.1FyoZr, <br /> 77�7-�f � J(f NI CLING PARTY y" / N <br /> SITE ADDRESS 7� /fit,,- <br /> Cl 77 f���V v), f CA ZIP Al <br /> RiUARR/q+ERA70R fW✓�""'�"1 7 (Ivds tg(- <br /> giLllNC PARTT Y / V <br /> DNA <br /> PHONE cal <br /> ADDRESSf Gt�rr-/ti��__� Wv ,�. PHOONE p2 ( ) <br /> CITY r`tIJ STATE `-�i ZIP a��6e6 <br /> �APO p <br /> �Land Use Appliest len 4 <br /> 804 Oist Laeet ion Code <br /> CONTRACTOR tww1/or S��Lb <br /> SERVICE REOIIESTOR RI CLI NC PARTT Y <br /> DBA PHONE at <br /> NAiLINa ADDRESS �Z�? S • �✓�, FA.Y K (�DT 1 <br /> A , „,1 <br /> Cl TY ree7 O srarE LA ZIP <br /> 611.1.196 ACKMOW.EDGENENT: 1, the tA11*1`219fed Rwner, Operator Or agent of same, acknOW(edge that alt site ardler project specific <br /> P9S/ERD hourly charges associated with this feoillty a activity will be billed to the party identified os,,the.RILLING PARTY on <br /> Page 1 of this lona. <br /> A to <br /> _ Pte' � I �"e, SAN <br /> 1 ela0 Certify that I he that the wp w ve this application and M fenaad wilt be done in accordance wi <br /> 7OADUIN COUNTY Ordinance Codes dd st , State am Federal taws. „An, Jyn <br /> PUBUC HEgLrH Lv�Niy <br /> /W'.�" ENVIRCNMENT, SEF7V�CES <br /> APDL tt�AVT's SIGNATURE : / <br /> rifitVe" P` `tel Date: <br /> title! - <br /> ALITHORIZATIOM TO RELEASE INFORMATION: In mmitlon to the above, when applicable, 1, the owner, operator or agent of sane, of <br /> the property tocated at the above site address hereby authorize the release of any end all results, geotechnical dote and/or <br /> environental/Fite "SOC90041t info . tion to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRCNMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time itt is Provided to m or my representative- ---CD 7 I <br /> Nature of Service Request:_ Service Code <br /> Assigned to <br /> / �I -/44- Eepl Oyee R �n(� Rete <br /> Dale Servi^.e Caraptettd 1 / <br /> further Action Required: Y. / X PROGRAM ELEMEWT�`j <br /> Fee AraratA1Rount Peid Vete Of Pa}+eer+t PeYwart Type Receipt a Lhaek M Recvd Ry <br /> 07-07-1997 09:56AM P.02 <br />