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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # <br /> RECORD ID # <br /> S INVOICE # <br /> BILLING PARTY <br /> `FACILITY NAME <br /> SITE ADDRESS <br /> CITY Sc �+��r <br /> ���.1i CA ZIP%J <br /> TtS�,(� <br /> BILLING PARTY Y / <br /> OWNER/ ERATOR /�77/�J�� <br /> PHONE #1 (76'7 )1.2.-L- <br /> DBA <br /> PHONE #2 <br /> ADDRESS <br /> CITY STATE ZIP <br /> APM # P Land Use Application # -- <br /> IBOS Dist Locat ionmCode <br /> CONTRA and/or ���.'� BILLING PARTY Y / <br /> S`TC <br /> "i. <br /> SERVICE REQUESTOR <br /> x4ZCJ1� <br /> DBA <br /> ( ! PHONE #1 <br /> L/J�,�. J(��� _ <br /> MAILING ADDRESS t` o,- �O F�/�#` <br /> CITY <br /> �n.-� - STATE ZIP �C 2-''sai� <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of sane, acknowledge that all site and/or project specific <br /> PNS/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 /> 1 also certify that I he lication and that the work to be performed will be done in accordance with ell SAN <br /> JOAQUIN COUNTY Ordinance a and St ds, Sta;ederat laws. PFIC���D <br /> !PAYMENT <br /> CEIVED <br /> APPLICANT'S SIGNATURE <br /> �i AY z 11998 <br /> Title: �- t" Date: J ld <br /> SAN JCAQUIN COUNTY <br /> PUBLIC HEAL�I�U ccccooW <br /> -Ediame, of <br /> AUTHORIZATION 70 RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, DIVISIc1u <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data R*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 /> T Service Code <br /> Nature of Service Request: C) .�p <br /> Assigned to ` ' �"t-A 'n` Al `�, ' Employee # 5 Date J/ <br /> Dale Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT Z 3 h <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> -N <br /> �q8p, oo S ?,i.� ✓ 4sr3 <br /> REHS SUPV / /__ ACCT _/_ UNIT CLK _/_/— <br />