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SERVICE REQUEST anl�i51211z�'I on J (EH 00 61) Revised 8/23/93 <br /> ATY I # )i RECORD ID # INVOICE # _ <br /> FACILITY NAME 50k hIsn4 7-CL-vevi 5ILr2, * 17&+7 DILUNG PARTY Y- / N <br /> SITE ADDRESS 104& W} <br /> CITY 1 9nte,Ga CA ZIP -1553& <br /> OWNER/OPERATOR SDu}h landrdll0n BILLING PARTY / N <br /> DBA (7-QQe,leven S}eIe, � 1-7&0r7) PHONE #1 ( Z4 <br /> IZ5 ) 737 . 4 � <br /> ADDRESS �ZUC) �}Orlerlclgt�. Mall FJ. 4 10 q 1 `QPHONE 92 (gI�5 ) 46,3- Z'711 <br /> CITY plga5antvn STATE GA ZIP <br /> FAPN # Land Use Application # <br /> IBOF Dist Location Code <br /> 69NFRABiBR-and/or <br /> (-a <br /> /- <br /> SERVICE REOUES7OR E-I l_ OC?5bin (.J,DI��I-n; iF� 2 U' an1I"D BILLING PARTY / �/� YA4LCV'3 <br /> DBA /Aneri� TI>r 'lay anA PHONE #1 (�'Y' ) NA& -MAILING ADDRESS 1p./D UWG Aycnj6 FAX <br /> CITY ./o-,rDmehTD STATE GQ ZIP 11151?1265 <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 S <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> c <br /> APPLICANTS SIGNATURE <br /> �l "� yy 1 1 <br /> Title: /'r.Y YI} {-DT , 111,'II21'1� �Q(7r (Xa+l1�Y� Date: <br /> r h <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 <br /> tt provided to me or my representative. <br /> Nature of Service Request: ��1�/�L�Z-"tRl 6.- �O f� Service Code <br /> Assigned to (kAe,U&21 1 Employee # Z412 52) Date --4-- /�-7 /;R .,. <br /> Date Service Completed / / Further Action Required: Y j N PROGRAM ELEMENT !i L)L� <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> Z 2ti z <br /> REFS / / SUPV �_/ /_ ACCT __- <br />