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2-1996 4: 14PM FRO' 'AYNE SIMMONS 91S 487 5983 P. 2 <br /> SERVICE REQUEST (EK 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD 10 # cl l INVOICE # <br /> t,JL oaGj I d g <br /> FACILITY NAME <br /> t .I BILLING PARTY Y / <br /> SITE ADDRESS �T7^� G A l� - Q �y <br /> CITY 5'roc CA zip <br /> /9 ^J` <br /> owNER/OPERATOR �x'C U� I�MPT4V BILLING PARTY <br /> DBA 7 PHONE #1 <br /> ADDRESS / ` `O/•n"/A��`'`I �l PHONE #2 C <br /> CITY Co�CP.eb STATE ZIP f5 Z `e <br /> p�APN N Land Use Applicat SOn +Y <br /> DOS Dist Location Code <br /> CONTRACTOR end/or 6. <br /> SERVICE REOUESTOR ✓TMeMAI y� D <br /> DBA PHONE 41 (Z Of >-N�7y/- 0O'' 23 <br /> MAILING ADDRESS " '- �J �3 nFAX # C Zpf <br /> CITY 5-� -r�� STATE l-� ZIP 91'"1 <br /> BILLING ACKNOWLEDOE14ENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PNS/EHD hourly charges associated with this facility or activity wilt be billed to the party identified as the BILLING PARTY on <br /> Paga-1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will IpfomF-K-fordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNNIAT <br /> Title! URE <br /> )Owe, -S�°� /JZ,15T Deta: 3��Z/�NJOAQUINL,UUNTY <br /> --r—rov6F6 I I EA6TI 16EI1VI C ES <br /> ENVIRONMENTAL HEALTH DIVISION <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 $6 soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request- U Z41 a7-CU2 <br /> Q Service Code <br /> Assigned to I , `mac 1�, Employee # <br /> Date Service Completed / / Further action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> LK <br /> -/ --L <br /> .x <br />