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SERVICE REQUEST (EH 00 bt) Revised 8/23/93 <br />FACILITY ID # <br />Date of Payment <br />RECORD ID # <br />,l ) <br />INVOICE # <br />0 31 o S�s <br />FACILITY NAME r t �W BILLING PARTY +' / N' <br />SITE ADDRESS ZS !� 5O • T�LS�T'� ��SS <br />CITY CI CA ZIP '{ J31� <br />OWNER/OPERATOR % P C om) l fz c 0 0 CT 5 BILLING PARTY Y / C <br />DBA 1-� ��X 403 r6 PHONE #1 (Ii ),17D - 5-4"// <br />ADDRESS 54--iL PHONE #2 ( ) <br />CITY f �—t �� t STATE ZIP 90 7 0 Z <br />APN # Land Use Application # <br />r F <br />SOS Dist Location Code <br />CONTRACTOR and/or /' Q <br />SERVICE REQUESTOR (7 A^ -JC: BILLING PARTY <br />DBAy -� -(-7 �-, 11 Ta T PHONE #1 ( 5 lo)SS! - J`SS S <br />MAILING ADDRESS 041 5IE7Z�v, 0-l' Scan T FAX # (S 10 )S -Si - -78 8 <br />CITY `J ' 8L- n! STATE ( A ZIP 9 S <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PHS/EHD 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 />I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. JUL 1 JUU <br />p 2199(_ <br />APPLICANT'S SIGNATURE9 Q.N1r1�� / <br />,AN JOA0 ON 1. <br />Title:rD'L: vv� Date: L�Z$��/ G, PUBLIC HEALTH SERB -iCr'� <br />_NVIRONMLNIAL HEALTH DIVISICJJ <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: <br />Assigned to "` <br />Date Service Comet —/—/- <br />C - <br />Employee <br />/ <br />C-Ertployee # <br />Further Action Required: Y / N <br />Service Code ( �� <br />Date <br />PROGRAM ELEMENT <br />Fee Amount Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />`35:01 U� <br />7L,29� <br />RENS <br />D 7 <br />_/ <br />/ / <br />SUPV <br />/ <br />ACCT <br />71 J / 7 y <br />UNIT CLK <br />_/ / <br />RENS <br />_/ <br />