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SERVICE REQUEST - 5_ - ,.� CIN 00 61) Revised 8/23/93 <br /> FACILITY 10 Y { } L ftS9ARA IAA { // INYO.ICE Y <br /> FACILITY NAME Sh v r/ S / Of✓ M 1"n / /'' K V -if- �a's BILLING PARTY / N <br /> ��1 <br /> SITE ADDRESS d-0 A lv' - s .t -) tLr22er feoa-cQ <br /> CITY /r O d 1 CA LIP • 7-5 d`4 0 , <br /> OWNER/OPERATOR /"Y I 1 !Z {7 777 Q o- '/ /' BILLING PARTY O / N <br /> 081, S{70Yr,6 A4 2L / �^ Li o`I L/T' a- s PHONE 91 , zOc ) 36ct- .3di 9 /7 <br /> ADDRESS �O�/ i�1��s �L� /� 6 lY0. S _ PHONE 92 (�O )3/0 9. 34'/`x '7 <br /> CITY •L O f STATE ZIP 7'5Z +0 1\ <br /> APR # Land Use Application Y <br /> SOS Dist Lacatlon Code \\ <br /> CONTRACTOR and/or <br /> SERVICE REOUESTOR C- Z1 �L' -1-Y- BILLING PARTY T / N <br /> DBA PHONE Y7 C 0 ) 4-6 <br /> MAILING ADDRESS .lCC,-tJy-3S � �(•U W � ��Z � � FAX Y C � �y ) L6- <br /> CITY J / ; r- IL f �2- BTATI (:'�A� ZIP 0 5^ <br /> BILLING ACKNOWLEDGEMENT: 1, the Irdersisnad owner, operator or agv,4 of am, agknowtedgg that Bit sit# and/or project specific <br /> PNS/EHO hourly charges associated with this facility or AOCivitY Will W hilted to the party identified as the BILLING PARTY an <br /> Page 1 of this form. <br /> I also certify that 1 have prepared this lopligatlon end that the LLQrk t-q hY perfermod Will tie 4" in Accordance with sit SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standar 6, Iwo and Fa rat laws- p r <br /> APPLICANT'S SIGNATURE <br /> Title: 19y,0 <br /> AUTHORIZATION TO RELEASE INFCRMATICR: 10 901t1pil to the AhoVe, mtkw Wptisahtgr 11 the owner, Wgrgtgr or agent of lame, of <br /> the property located at the above site 4ddrs6t hgregy awthgritl the r#LeOss of any Ind All re6Uttl, Brgtsohniaal data and/or <br /> envlrormentat/site aassesarnt information tv 5AN 4OAQUIN QUANTY PUBLIC Hfw6LTN 16RVICEB SRVIRONMUTAL NMTH DIVISION As soon as <br /> it Is availebts and at the lame titre it is Nrgvidad to ma or W representative, <br /> Mature of Service Requests BArvlce code <br /> Assigned to "�1 Az laptoyse Y Dace /6 / <br /> Date Service Completed ��/ / further Action Required: Y y N PgOGtAM ELEMENT 7 .3 4" <br /> fee Amount Amount Paid Data of Payment P#ymant Type Rog lipt Y Cbagk Y Movd ly <br /> V <br /> r <br /> ACCT �J_J� WIT cu <br />