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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br />FACIIiTY ID # RECORD ID # INVOICE # <br />FACILITY NAME r' Iejj 96rdICC r �� �II BILLING PARTY Y / / w <br />SITE ADDRESS <br />CITY S10( Iyly CA ZIP 61SOA-01 <br />OWNER/OPERATOR 4l II LI BILLING PARTY �,,�r0 / N <br />DBA PHONE #1 ( Evo ) IY I"✓ ' 1D0 <br />PHONE #2 ( ) t� LJ - l[�I"�`✓ <br />CITY 06ffArd STATE C— ZIP �I`[�✓4O <br />APN # Land Use Application # <br />DOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR <br />DBA <br />BILLING PARTY r�Y / <br />PHONE #1 ( 5 ) ZL 1��/� <br />'�_ <br />MAILING ADDRESS �,,� -14 t1OR- TOOK 1-( ur� (14154& <br />t 1'/&FAX # t JIV )P4-7 - <br />/ <br />CITY ! n`T!O AUEl/ STATE C_ ZIP (14154 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS/END 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. <br />I also certify that 1 have prepared this application and that the work to be performed wil l:bp dyne I ordence with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. J U L 1 b <br />APPLICANT'S SIGNATURE <br />i��bTAR��C� <br />SAN JOAQUIN COUNT <br />qqqqIIqq{{ VICES <br />Date: %E�YiM(7HEAL?FIplViclpn! <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of some, of <br />the property located at the above site address hereby authorize the release of any and all results, geotechnical eta 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: <br />_ � <br />Assigned to ut I � <br />Date Service Completed , <br />Employee # "1 q D _-� - <br />Further Action Required: Y / <br />Service Code yJ� <br />Date -:�—/ �' / i_. I <br />PROGRAM ELEMENT 'Q131 . ZZ2 <br />ADDRESS l�b w111OW f�4. Rd-) sI'1'l �Pi �w <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />Ma <br />,?q-7oz- <br />-71,lq <br />V/ <br />�93� <br />__/_/_ <br />ACCT <br />RENS <br />__/_/_ <br />SUPV <br />_/_/ <br />