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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACIU TY ID # / t / RECORD ID # �.� INVOICE # - <br /> FACILITY NAME C,/": ,I/ BILLING PARTY Y <br /> SITE ADDRESS 7,p' <br /> CITY ac,�,<ori CA ZIP <br /> OWNER/OPERATOR J U BILLING PARTY C Y L./ N <br /> DBA PHONE #1 <br /> ADDRESS l<</�� /V//L/ �L /J/- / 7PPH,ONNE #2 ( 1yCID) <br /> CITY 74— STATE ZIP <br /> APN # p Lard Use Application # <br /> IBOS Dist location Code <br /> -tMIWORACT and/or <br /> CE REQUESTOR //T 0 ��� BILLING PARTY Y / �i <br /> � <br /> lr y <br /> DBA PHONE #1 ( )�' AL/Z�— <br /> MAILING ADDRESS / >?Z/ Z l.+/C /0 t'k�-) / r� n FAX # <br /> CITYP1/ti42 .ny-i,Io✓Gt STATES ZIP /CS� 76 . <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/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 form. t�PAY,Fv,'1E�CNnr <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in ac orcam rautA ell SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, �tje and Federal taws. JUN <br /> /moo DlI, P �� 1997 <br /> T <br /> APPLICANS SIGNATURE <br /> NJOACU <br /> IN <br /> N1 Date: Com" -)--C17 <br /> E 6NMENTAi(HES RVQ., <br /> Title: /7<�"0%9,�,�/C- <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 at( 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. T <br /> Nature of Service Request: �' � �L Service Code <br /> Assigned to AY'n Employee # �" Date _/, _/� <br /> Date Service Completed _/ / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> G <br /> RENS C / LO / SUPV /_/ ACCT y -L/ 1 UNIT CLK _/_/ <br />