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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # ��\ INVOICE # <br /> /� / � <br /> FACILITY NAME f'b7l 7117-,)(2 ,A ��/PAQ �Iw1 "�/ BILLING PARTY / N <br /> SITE ADDRESS <br /> CITY / -7-0 CA ZIP <br /> OWNER/OPERATOR /C I�i�/ I//S /y 7A\/h/Qn <br /> yu 1.1/ / �/ BILLING PARTY Y / N <br /> DBA ,N, (_./ i'D/l./J/ P J_ (Z h//�'/ `-'G PHONE #1 <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> Fqpg # Land Use Application # <br /> BOS Dist Loca Lion Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR l.id"7 - ��U2'�"�� ���L� nfp.� //) BILLING�PARTY <br /> DBA /) n PHONE #1g-0L�> <br /> MAILING ADDRESSy I-�DJ�' // // FAX # <br /> CITY /DC K. TDIJ STATE C4 ZIP %S Z/J <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 I 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. PAYSMEW'i <br /> APPLICANT'S SIGNATUREFEB 23 1990 <br /> Title: UPrC/�9 //D.a_`. QnJACi �, Date: L 2� � oAIV JOr„��,�,.�,�UIVT. <br /> VV11tPUBLIC HEALTr;SERVICES <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner;-��prrbiN��Ta�ErfNfid'(L€hMi®,I1gRI0N <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 <br /> 11 provided to me or my representative. <br /> Nature of Service Requ�eesst:/�r V� L ��! G� 1✓ Service Code <br /> Assigned to� . Y 'l/1`��� _ Employee #Cn(,(�) C/ 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 /> `7f lY� <br />