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SERVICE REQUEST _ e/�:; (SERVREO) Revised 8/:3/93 <br /> =FACILITY 0 RECORD ID 1t NNVOICE K <br /> s <br /> FACILITY NAME lq.,.ts. N'*-L�lnA.e BILLING PARTY Y / N <br /> `I <br /> SITE ADDRESS 0 f ! '5'. VtSttD (7-� <br /> CITY CA ZIP <br /> OWNER/OPERATOR BILLING PARTY <br /> DBA PHONE e1 ( ) <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> ArN Y Land Use Application e <br /> IDG Digi L6Ci:Idn COLE <br /> 17ONTPACTOR aid/or /� <br /> SERVICE REOUESTOR /r U1(JI(/�;' F �Q,L�IR,'hL`U I ! BILLING PARTY (DY <br /> YI { N B <br /> DBA 0 r L�ICQ.f I{ ,�I �,v� `t)L PHONE A'1 (. �� <br /> NAILING ADDRESS A1,I ISI����JJZNt> � /' Q �+ FAX # ( ) <br /> CITY ShCA2 1, ,E7 T 7 STATE C ZIP / `.fid I� <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that ell site and/or project specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the party Identified !_BILLING PARTY <br /> on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in a coldoilee with ell <br /> JOAQUIN COUNTY Ordinance Code �a�n/dtandarrJds, State and Federal laws. AUG 0 `; 1994 <br /> APPLICANT'S SIGNATURE ✓�'I •`-' "!V{RGHPPIEP6,[1 IE !rF <br /> Title: PERMIT/SERVICES <br /> �7�/(�+ Date: t' <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operatcr 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: ' Service Code <br /> Assigned to SrA Employee 0 19(p Date <br /> �y�( <br /> Date Service Completed /�/ 7`T.. Further Action Required: Y / No PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt t Check R Recvd By <br /> 1 ,p <br /> RENS _/_/ SUPV _/_/ ACCT -L/—L—/—qA UNIT CLK _{ / A <br />