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�1., • SERVICE REQUEST (Tank Ir, a11oh (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # r l /� RECORD ID # INVOICE # <br /> FACILITY NAME �7olcle�en 5tyc. nµ C7(a BILLING PARTY Y- / N <br /> SITE ADDRESS U5 "J YOYVII <br /> CITY Man+CGa CA ZIP q 1 G,/-2> i _ <br /> OWNER/OPERATOR /'7l�ft71 �G,�.COroora1DYI BILLING PARTY / N <br /> DBA C7-elCV5 <br /> Gil t * ?,1-7c7&)orc * �-7G7&) PHONE #1 (q2 ) 737 - 4Z14 <br /> ADDRESS 5jZ5O f}5t�erjda Mall U . *3z0, PHONE #2 (g25 )�i�- 271) <br /> CITY 1" L,-2 STATE �'/"' ZIP 9�5�$ <br /> APN # Lan <br /> p d Use Application # <br /> ISOS Dist Location Code <br /> fifer �J <br /> SERVICE REQUESTOR I�NL mss}- r 610L)p (dl 'p •. aja L 2%Z O BILLING PARTY Y / N <br /> DBA Aden} TOr LO/ Ot>1 g"'A Com¢. PHONE #1 (�) <br /> MAILING ADDRESS (050 Howe /✓ J F2 FAX # ( 91G ) 64(0 - 4(07 <br /> CITY r7cGra mov"ro STATE GA ZIP JDZC72 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/END 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 /> C°AY E l <br /> I also certify that I have prepared this application and that the work to be performed will be done in alaW,r�ecy Vora ll SAN <br /> i <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> � ��Qy000 , JUN 16 1998 <br /> APPLICANT'S SIGNATURE <br /> 1 �21'1Q WfP�dI10✓I Date: �L �1 SAN JOAQUINHEALTH GUUNSERVICES I'Y <br /> Title: wn` �Ur T Z4f 1� PUBLIC HEALTH CES <br /> —�'ITJ'Ifi171R1aENTAL HEALTH DIVISION <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 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 provided to me or my representative. <br /> Nature of Service Request: ,, `1.��knl�.�-.� Service Code <br /> Assigned to �L.- N�S��� nits. Employee # ScNn3 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 /> RENS , _/ /_ SUPV _/ / ACCT /_/ UNIT CLK <br /> F <br />