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(EH 00 61) Revised 8/23/93 <br /> SERVICE REQUEST <br /> INVOICE # <br /> RECORD ID # <br /> FACILITY ID # �� <br /> -}_i C ' � IEEE= <br /> ILLING PARTY Y / N <br /> jIG N <br /> FACILITY NAME �L\ �UN•I I` <br /> SITE ADDRESS <br /> CA ZIP <br /> clTr � (jN I(zC r\ <br /> BILLING PARTY Y / N <br /> OWNER/OPERATOR � )11L R <br /> PHONE #1 ( ZOgt ) -..y�=.__ <br /> DBA y <br /> PHONE #2 ( ) - <br /> ADDRESS <br /> CITY STATE ZIP <br /> p APN # FLand Use Application # <br /> IBOS Dist Location Code <br /> CONTRACTOR and/or (� <br /> SERVICE REOUESTOR NC <br /> � k1'QCN \ 1\O WL IS CO BILLING PARTY Y / N <br /> DBA <br /> PHONE #1 ( ) <br /> MAILING ADDRESS � Q• /�Y �1 � 1„iV`-� ( C FAX # (510 <br /> C`\ <br /> CITY ✓TTN I NA� Qk STATE C.A ZIP C� isms <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 /> 1 also certify that 1 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. 'A TSB r- <br /> Q \ RECE)VFtr <br /> MAY I b 1997 <br /> ;'I <br /> APPLICANT'S SIGNATURE <br /> Title: F11N1'01QCH Ch1Gyi��( T(Z�Jul75 CG Date: S O -1 <br /> GAN (JUW COut, <br /> PUBLIC HEAL THLS' 'n <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owrKft\PP *?Ef?rAfgMA?I-tsa"', of <br /> the property located at the above site address hereby authorize the release of any and at[ 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: Service Code L`14 <br /> Assigned to {� .\ �"`.. Employee # Date <br /> Date Service Camteted _/-/- Further Action Required: Y / N PROGRAM ELEMENT Q <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 2 �- 1;� � alae <br /> REHS / / SUPV / / ACCT / / UNIT CLK <br />