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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RRECORD ID #C d��p O 3oZ INVOICE # <br /> FACILITY NAME 1 V11�DI �.. C.0 /G7�X0 BILLING PARTY <br /> SITE ADDRESS Z Co. 1'OSP/yJiY 1/ <br /> CITY 1'' %ecq , CA ZIP <br /> OWNER/OPERATOR ' l {/11 Q 1 L, CO BILLING PARTY / N <br /> DBA S/}f'�.�, PHONE #1 ( 2CXo ) 2 6 r- - 7-40C) <br /> ADDRESS Z /rI 3 W. (fd.ji4m apoR e, PHONE <br /> gPHONE #2 ( OD) 42-&- 02-SS <br /> CITY Se�1�T�r�C STATE W A . ZIP 9 <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR /'/(L ed,%) T W^e^JT �JC� BILLING PARTY_ Y / <br /> DBA �J S(�A, 'Pin,+ PHONE #1 421 )76V 6909 <br /> MAILING ADDRESS 1 .Q.((R)O"— '(']� r^ FAX # ( <br /> Q—I ) <br /> CITY Saa AJ n�2,pog STATE 1.t't. ZIP PAY <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site a %$ cific - <br /> PHS/EHD hourly charges associated with this facility or activity wilt be billed to the party identifiedes the BILLI TY on <br /> Page 1 of this form. 6NVIptja <br /> 9 <br /> GNME HED TICyoN <br /> I also certifythat I have NT,q(hf SFRVI <br /> prepared this application end that the cork to be performed will be done in accordance'�rklp, SAN <br /> JOAQUIN COUNTY Ordinance Codes "d standards, State and FederaL Laws. I0Tv <br /> APPLICANT'S SIGNATURE ,:-/ Zny,,L /qq <br /> Title: �.,e,-[„� C.On1S7' ��� 'f' Date:_ I/-VzqS- <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 r0base of any and alt results, geotechnicat 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 some time it is provided to me or my repr2nntative. 111 (((( <br /> Nature of Service Request: aQ Service Code I cf l[j <br /> Assigned to ,��Qi�-C it J��—i Employee # T s l Date / T/ <br /> Date Service Completed j / Further Action Required: Y / N PROGRAM ELEMENT h <br /> O✓' <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> `' 351_UU L�*9o(oaSS aa'l.00 <br /> REHS <br /> �/7-3 SUPV _/ / ACCT <br />