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' SERVICE REQUEST (p S !,b (EH 00 bt) Revised 8/23/93 <br /> FACILITY ID # G� 3 ? 2 2 RECORD ID # �Y5'�(/J INVOICE # VVI Gl <br /> FACILITY NAME r 6 ytT, e ,r -T f Gin s " Co ,, / YJ BILLING PARTY VVVY /' N <br /> SITE ADDRESS LI �� ci C I OCAJ <br /> CITY ,�a,C `/ CA ZIP l J 3 w <br /> OWNER/OPERATOR S, �L wt F 6 S �)oo.i �7- BILLING PARTY Y / N <br /> DBA IY ONE #1 ( ) <br /> V <br /> ADDRESS ONE #2 ( ) <br /> At- 0 6 1995 <br /> CITY STATE ZIP <br /> IAPN # Land Use AppLicati on # <br /> C <br /> o (/ PERMIT/SERV Egos Dist Location code <br /> CONTRAC <br /> an /or <br /> SERVIICETREQUESTOR i'YV'� \ i pes ` �• �- � IXL <br /> ( / C -� SScC BILLING PARTY Y / N <br /> DBA TC{L/1 J 4Q•IJ�_M W-1-IO d "YSSoL , �Y�q PHONE #1 ( 05 )Z72' O 9 <br /> MAILING ADDRESS "I I r�+ln `�,CtNV`)n` ,, ST• % FAX # (�bc/ ) 7yJ— c-8-92 <br /> CITY C , ` (fV 06W UUy STATE ZIP 3 Y~/2 <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 wi Ll be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> 1 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,/Sttate and Federal laws. C/, <br /> / <br /> APPLICANT'SS IIIG�GNATUR,EE ::�1� C�'"`-'� '7" ` `.� \ /,• J' <br /> Title: �J( X_i!/c"vI UZ — �yStoc; 2LC_ Date: �0 J <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicabte, I, the owner, operator or agent of same, c <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/c <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as sc <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: ) ) / ,Y�^1�9 Service Code 1� <br /> Assigned to, c' / !.�/� / Elip loyee # [/� Date �/ /_ <br /> Date Service Completed / / Further Action Required: / Y I / N PROGRAM ELEMENT <br /> Fee Amount f,A'moun�\ id Date of Payment Payment Type Receipt # Check # <br /> AA <br /> RENS _/ / SUPV /_/_ ACCT / / UNIT CLK <br />