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t • <br /> SERVICE R/EQ�U,EST(� r (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # II I t1 RECORD ID # I / 1 - I'' 1 INVOICE # 0/� 997 <br /> FACILITY NAME L ��r G/7=UR.-1q �L ./_--/// BILLING PARTY Y / �N <br /> SITE ADDRESS I g0 - S� L.�TrT lu-'I" I"l� PAYMENT <br /> RECEIVE® <br /> CITY CA ZIP 9 3 � ri. 2 5 T"i <br /> OWNER/OPERATOR {N c- <br /> DBA �=f�< < PHONE #1 ( O ) 73� - Y. <br /> ADDRESS L uGfV a7YL S w ,"- 3"� PHONE #2 ( ) <br /> CITY L)L—( S STATE d � ZIP �D ✓�:.. <br /> ppN # p Land Use Appticati on # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or I ( ((JJ <br /> SERVICE REQUESTOR G (G(-�o F"I ��- BILLING PARTY Y <br /> DBA LE / C.O Lth�10 /� Sc7 G/�.T}�-� PHONE #1 ( -- - o..a <br /> q/k /V3 tise� <br /> MAILING ADDRESS ZITS St FAX # ( q/c. )y_y3 - 6ss3 <br /> CITY Rt--, Y>"L/-J7b STATE ZIP 4 3(6 <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. <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 laws. <br /> tl'�/b �'N <br /> APPLICANT'S SIGNATURE <br /> Title: G� �l� <br /> �—.fps== ' "f-- Date: ����M A(((1��11 6 171 nJ, v <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner,ppl r tgl'Q.1�8dr1���'PICaFm�eI of <br /> the property located at the above site address hereby authorize the release of any and all Erlwlx G�h1 ' IhHR�OL �IVISIVN <br /> environmenta L/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEAL H D 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: YM�\/(� 1/"� �(\�/�a � � Service Code �1 <br /> Assigned to F4� . � ' ' "` C ��"`�'C6p Loyee # 3 -3 Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z . <br /> Fee Amount Amount Paid Date of Payment Payment T pe Receipt # Check # Recvd By <br /> �o <br /> S ACCT y5/3L / UNIT CLK <br /> f _ <br />