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01-17-1996 09:3ZA11 FROM TO 15108958426 P.02 <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # ( ► 'n INVOICE # <br /> FACILITY NAME _\N �`l> BILLING PARTY Y / N <br /> 11 - <br /> SITE ADDRESS LV \1 C <br /> CITY I �7�}C �D S� CA ZIP Cls, , <br /> I <br /> I <br /> OWNER/OPERATOR BILLING PARTY Y / <br /> I ` <br /> DBA L� �� �\ PHONE #1 <br /> ADDRESS PHONE #2 <br /> CITY STATE CA zip <br /> APN # I Land Use Application # <br /> IF SOS Dist Location Code <br /> CONTRACTOR and/or I <br /> SERVICE REQUESTOR C - Co V� V_Ly`r� BILLING PARTY / N I . <br /> DBA PHONE #i ( SCa ) o is 7�15 -2 <br /> MAILING ADDRESS ;\�l� �Ja��� \ e �� FAX # <br /> CITY I �Q h G�l�`(�� STATE C ZIP 2f 5 7 <br /> BILLING ACKNOWLEDGENENTk I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHO hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page i of this form. <br /> I <br /> I also certify that i havepr ed this application and that the work to be performed Will be done in accordanfy�oR «.( 6(�}! <br /> JOAQUIN COUNTY Ordinance C =Amard >� �dc>r-Fal taus. g �FGEIVIAPPLICANT'S SIGNATURE c C l <br /> Nov 2 4 N98 <br /> Title: 1'01-0 _�W' G f Date: r0\ �C�\0.� <br /> �- SAN JUAOUIN CUl1N7-Y' <br /> PU!_lUC HEALTH SERVICES <br /> ENVIRON h(F i ALT�{UIVISInN <br /> AUTHORIZATION TO RELEAS INFORMATION: In addition to the above, when applicable, I. the owner, operator or agent r;tTa , of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirormental/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: /„ D (, Service Code <br /> Assigned to Employee # Date <br /> Date Service Camplet / / Further Action Required: Y / N PROGRAM ELEMENT k F <br /> I <br /> Fee Amount Miount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> i <br /> SUPV _� / ACCT !� J UNiT CLK _/�� <br />