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f� rpy `isl3-a • SERVICE REQUEST <br />—ILITT 10 <br />RECORO IDFAC <br />SITE ADDRESS / V I«s r 4 Ir 1 W <br />CITY I QG/1"?�N la 2iP <br />(EH 00 61) Revised C/23/93 <br />INVOICE r <br />BILLIWO PARTY &&a/ <br />S` Qitlb <br />P J R- <br />BILLING PITT <br />T /� <br />OWNER/OPERATOR <br />PHONE r1 ( ) <br />DRA <br />PHONE r2 <br />ADDRESS <br />�� -• .... - . VATE <br />CITY <br />ZIP <br />APN land use Appllcati— 1 <br />805 D l s t <br />Location C We <br />- "COWT RACTOR and/or•.; s rL� t� r 1 <br />BtILIWG PARTY <br />SERVICE REOL�STORj� IJII 7 <br />CD �, S l <br />� <br />_ <br />PHONE rl ( _i Z• �U / Z <br />_ DBA 1 ±�`� <br />MAILING ADDRESS <br />CU <br />STATE <br />ZIP <br />CITY <br />V VILLIWG ACKHO.0LEDGEMEWTI: I, the understpnad 9"wr, gator or agent of 1sne, sckrowledge that ntl site and/or project PANTspocY lc <br />bo blued to The Party identlrlLf• heI�IBILLING PARTY on <br />PHS/E"D hourly charges aasoelatoq with this faculty Gr activity will <br />YIa 1 <br />Page 1 of this for*, , : <br />R�C�I�Nxz � <br />-also cartlfy that I haw prepared this application end that the work <br />lava. <br />to be perfor>�d will be 1ypn n 7 ln�rdhro" with •ll cAN <br />UCI. 1 J <br />JOAQUIN CaNTY Ordlnenee Codes end Standards, Stets federal <br />N j(-, <br />APPLICANT'S SIGNATURE t, <br />Titter <br />D � f ` <br />Deter <br />AL NSC <br />— I''' D!V!S!pN <br />o <br />AUTHOR I ZATIOW TO RELEAS9!INFORMATIOW: 'in addltlon to Above, <br />ovet <br />,whenhe eeaecaof any andoll <br />bia, h�sults ryeotechnlcalator or tdata <br />of s�f <br />"/or <br />the property located at the above jilts address hereby aur h <br />environmental/site assessment Information to SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as coon as <br />(t is ovallable and at the same tim It Is provided to me or my representative. <br />Mature of Service Request,'- <br />~Assigned to �W ,lQn Employee r <br />Data Service Completed further Action Required: T / N <br />fcr Ameo�nt -,i AmountP a I ---7T Date of Payment Poytaent Type Receipt r <br />Service Code 1 <br />Data Z PROGRAM ELEMENT <br />ELEMENT (? <br />Check r Wacvd By <br />:'SuP1► 1•_JJ ACCT _J_J UNIT CLK <br />i3�C�� <br />