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SERVICE REQUEST (SLRVREQ) Revised 8/?3/95 <br /> FAC It I1Y IDN b 5 7 RECORD IDM <br /> INVOICE N r <br /> FACILITY NAME �„] S is .,�) r ' <br /> BILLING PARTY <br /> SITE ADDRESS <br /> / CITY Ir 'a dc\\ CA 2IP <br /> OWNER/OPERATOR <br /> .In <br /> V IN 12 00 !j� BILLING PARTY <br /> M <br /> DBAZnC 1 —' <br /> / I o I ' PHONE N1 ( ) <br /> Y ADDRESS << Ni� �SGpOhC v �L PHONE N2 ( ) <br /> CITY _J/�Grar--� i STATE �-� ZIP <br /> —APN N p Lend Use Application N <br /> IBOS Diet Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQl1ESTOR ct— —j ' �\o �.�1 r,FJ r BILLING PARTY <br /> Y / N <br /> DBA PHONE 01 ( ) <br /> NAILING ADDRESS <br /> e..,.._"" FAX N ( 7 <br /> CITY STATE ZIP _ — <br /> r�. -iT.-i'--- <br /> All LING AC ONLEDGEMENT: 1, the Inder,igned er, operator or agent of aeons, acknowl edg�Q �?[ a t6, <br /> PIIS/FIID hourly charge, associated with this facility or activity will be billed it ow[edgFo 11,11 m V /or project speci t I <br /> Pnge 1 of this form. �IVV f2 f ed as the BILLING PARTY an <br /> fNVP�BCI�CCAy�gPl�/. �9s4 <br /> 1 also certify that I have prepared this pplicatfon and that the work to be performed NfIV q�TNa,QJ c� <br /> JOgn7111N COUNTY Ordlne a Codes and Stands State and Federal laws. � �y��rdance with all SAN <br /> y�N/S pN <br /> APPLICANT'S SIGNATURE <br /> Date: �1 g6n <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, t, the other, operator or agent of sane, of <br /> the property located at the above afte address hereby authorize the release of any and all results, geotechnical data erd <br /> environmental/site assessment Information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALfN DIVISION ae so/onor as <br /> it Is available and at the same time It is provided to me or my representative. <br /> Nature of service Request: i�' F <br /> Service Cade <br /> A<signed to _ L i 9 �-- N Date <br /> ---"-_ <br /> Erlpl oyes <br /> Date Service Coaple[ed <br /> further Acton Required: Y / N PROGRAM ELEMENT <br /> Fee Arnatitt Amount Paid Date of Payment Pa <br /> Yment Type Receipt N Check N Recvd By <br /> RENS /�/ <br /> �r <br />