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r <br /> SERVICE RE WEST � (SERVREO) Revised 5/13/93 <br /> FACILITY 10 # 10�{''' RECORD N N6'PRR <br /> FACILITY NAME M t 1=-X7 # <br /> SITE ADDRESS Z eM �� EAC-# = <br /> �� /LI' Jj c <br /> CITY IVIlAT ecx. }C✓� CA ZIP I gg }� <br /> OWNER/OPERATOR 70VS (F� PL-A 1A�- TFto�'1 E1`\ BILLING PARTY <br /> DBA " AC'U _ PHONE #1 (Z) �'j. <br /> ADDRESS �—'2CX-D aCnj H>S LAZA- pe PHONE #2 ( - ) <br /> CITY II/1006-5 Z-0 _ STATE A ZIP ys � <br /> APN # Census BOS Dist Location Code City Code -••--- <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR BILLING PARTY Y / <br /> DBA PHONE#1 ( ) <br /> MAILING ADDRESS FAX # (. ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/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 Lode /tJandards, State and Federal la�� - <br /> APPLICANT'S SIGNATURE �^ °""—� <br /> Title: ��y �✓/Z ! Date: .3 Z l � <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 Re//quest: //r�,� /�Q� Service Code <br /> Assigned to�J�PC ,ff� ��C. Employee # 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 /> REHS _/_/__ SUPV _/_/__ ACCT __/_,�,_ UNIT CLK <br />