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SERVICE REQUEST ..r' (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # /�j INVOICE # q <br /> 1008-7-707C, <br /> FACILITY NAME .moi/ l J P/V OOVi-19 BILLING PARTY Y / <br /> SITE ADDRESS q5c? t�� /jAOOAfS110 <br /> CITY Sr0Gb9-r0/1.i CA Zips P <br /> OWNER/OPERATOR S�rG/ZI� I /�9/?/Z1/09- :Z /()C BILLING PARTY Y3 / N <br /> DBA PHONE #1 ( <br /> ADDRESS )01011Q1 43oy 117-70 PHONE #2 (Z09 )4166 - 86 I) <br /> CITY �i"Tc` 021VIL,I STATE ZIP 9520 j <br /> APN # - Land Use Application # <br /> FDist Location Cade <br /> ONTRAC and/or /y" <br /> SERVICE REQUESTOR � r t��/'�(//?�! Ni,//��/� 2, /`YI�C1T =BILLING <br /> PARTY Y <br /> DSA PHONE #1 (gpq )213 L�SCC <br /> MAILING ADDRESS V <br /> !'^ c, �/� r7� (� /5�pFAX # ( 2J )�- '779& <br /> CITY ' Ir C. C,l�+-+' STATE �J7. ZIP -/ 11s1, <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHO 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal <br /> Laws. <br /> APPLICANT'S SIGNATURE <br /> Titte: �t/ � A/r�S Date: 3 is <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 all results, geof6hnicai data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEAtTN DIVISIOII as soon as <br /> it is available and at the same time it is provided to me or my representative. MAR I <br /> Nature of Service Request: C�v�u� ��ll)r�< rr Y' Sd� _ <br /> �f <br /> Assigned to d p" _ 1�"� _ Employee # Date ENTA u HF <br /> Date Service Completed / / further Action Required: Y / N PROGRAM ELEMENT 7-3 194L Q <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> w 3L4 J o <br /> RENS _! f SUPV �/ / ACCT // / /_ _ UNIT CLK �/ / <br />