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SERVICE'REOUEST �S H Od 6U ReVlsed 8/23/93 a <br /> FACILITY ID # RECORD ID # / I / b pt- INVOICE # oa a q 7J <br /> FACILITY NAME BILLING PARTY Y / <br /> SITE ADDRESS <br /> 01 ldr. LrOI favi L Qas rc/+. J�CITY —ZPP CA ZIP - <br /> w <br /> SH <br /> OWNER/OPERATOR /4 ,6 L e6 4'1 129 5 BILLING�PARTY /)Y / N <br /> DBA /� `/ PHONE #1 <br /> ADDRESS oG J—f-7 / ,/L /9-/t/��/7 U /� 7 �y PHONE #2 ( ) <br /> CITY s/ �� K TDN STATE _ ZIP 1 15 D 7 <br /> APN # — Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or ,., 7 i <br /> SERVICE REQUESTOR HA'k)5..,�/�/ 6^' ' '� .4.T- BILLING PARTY 6//,� ��Y ,q/;�, N� <br /> DBA �J f1 PHONE #1 (Jo ) / - l�2T�7t- <br /> S'4 <br /> MAILING ADDRESS 7.-C' -- Obi ?2 C) L/ FAX # (010 I ) <br /> < d <br /> CITY ��FG"��—� STATE�.aL ZIP 3CJpf <br /> 9 ' <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all si te,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. DEC o 1 I99v <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 Codesndards, S e and rat Laws. <br /> i'LALih <br /> APPLICANT'S SIGNATURE G -Z / 1 <br /> Title: 1.� i / Ia�11J� �H�rwJs il�A. ✓�6ate; // /3o A-3 VI S <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, 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: (1?9 ' Lam"`c VA4 pticou!!C / Service Code <br /> Assigned to ��W� Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT , G 1 <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 3S UV <br /> RENS �� /_ SUPV _/ / ACCT / / UNIT C <br />