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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> =FACILITYD # RECORD ID # INVOICE # 90 <br /> FACILITY NAME 91\�J �Tl C, �✓ `�l 1 7 BILLING PARTY / N <br /> - <br /> SITE ADDRESS Ia✓ t Y�c_�-t c7 ti �n `� <br /> CITY Tock'/r CA zip `T <br /> OWNER/OPERATOR a r D e', IaBILLING PARTY / <br /> DBA �?Q K1 -C a4- PHONE #1 ( 2c' <br /> ADDRESS PHONE #2 ( ) <br /> CITY STATE ZIP <br /> APN # E Land Use Application # <br /> F 1 <br /> FBOS Dist I Location Code <br /> CONTRACTOR and/or <br /> r� // C� N, <br /> SERVICE REQUESTOR �.-� IU�L �Z- R' V C r i � __ BILLING PARTY <br /> �� /�' 1/ �3. � -T uy 6' ! J'e J(_ PHONE #1 (ZE ) ��JL- <br /> DBA �^` <br /> MAILING ADDRESS ° �` ©�1c �CJ� FAX # (11-1 )AL- <br /> CITY <br /> L-CITY I riC C / STATE _�_ zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that at( site and/or project specific <br /> PIIS/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 1 have prepared this application and that the work to be performed will be done in accordan��g{?AW Yf�"$�NA <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. C C EIVE D <br /> APPLICANT'S SIGNATURE r �� DEC 1997 <br /> _ SAN JOAQUIFI COUNTY <br /> Title: "/ - Date: - PUBLIC HEALTH ENVIRONMENTAL HEALTH SERVICES <br /> SIOM <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 /> environmentat/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: _5 Service Code , <br /> `� iAssigned to / °��L�� Employee # ._) Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT C) S <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS / / SUPV / / _ ACCT / / UNIT CLK _/ / <br />