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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # 00-;%4,��/ I C ,R/ECOR`nD ID # _ / .ryla}�r!`��/3 INVOICE <br /> FACILITY NAME IV a4e/ /{.�-u(7 ��l/f, nJLI�L(7QIl �V�7�1`GLC BILLING PARTY Y / N <br /> SITE ADDRESS ,,((�''�F/) + C ttrUCSP ky-� <br /> CITY /VlA0b eek//n�J/� //�� CA zip <br /> OWNER/OPERATOR /"l pc l:�f'L'� I,[�.(,f+^Pxcl �(4&0( I�tS{-�-(G"i BILLING PARTY Y / N <br /> DBA 2 PHONE #1 (2 ) SLS - 3Z)trz7 <br /> ADDRESS ,(IPC) , 60X )2 PHONE #2 <br /> [', ( ) <br /> CITY M SL�uL STATE Lr1.. ZIP (;724- <br /> FAPN # P Land Use Application # <br /> Ill BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR �0 BILLING PARTY Y / <br /> DBA J, PHONE #1 ( ZOL) fZy-_li; ?u <br /> MAILING ADDRESS I Z17�y/ //JJ FAX # ( / )�- =3 <br /> /v1 <br /> CITY O �7T STATE u`t ZIP q$� V I TT" <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 1 have pr red this application and that the work to be performed will be,dplpg,in accordance with at[ SAN <br /> JOAQUIN COUNTY Ordinance Standards, State and Federal taws. IYIFIF( 6 7997 <br /> SAN JOAQUIty GOUN i'r <br /> APPLICANT'S SIGNATURE <br /> ( =NVIRONMENTAL SERVICES <br /> Title::l Pay Dater C/ HEALTH DIVISION <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 /> environwntat/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: —\ -t-40,r— Cko-.� Service Code 0 <br /> Assigned to —*46 � Employee # 5975 Date <br /> Date Service Completed _/_/_ Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> CL (0633 <br /> RENS �I�• /_ SUPV / /_ ACCTlit / D 7/ UNIT CLK _/ /_ <br />