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lo, s <br /> SE VICE EOUEST (SERV Revis 8/ / <br /> '✓Y' <br /> FACILITY iD # RECORD iD # INVOICE # <br /> I-AC11.1Tr NAME ��`� �L/K V I`W •W�`o, ` El;BILLINO PARTY Y / N� <br /> =. � <br /> SITE ADDRESS 4'.3- { IOD 1 O0,,J <br /> CiTY S�a�K-t CA Zip q r5 LO"✓ ..; <br /> (VNFR/OPERATOR i/�I l� l�/Y L L - <br /> BILLING PARTY <br /> DBA l i/ 1 D PHONE #1 (C�-10 l- l L�& <br /> ADDRESS I- ID W I I Lo W I\0-1 <br /> ` 1 - , --J�- 900 PHONE #2 ( ) <br /> CITY ConCond STATE CA ZIP 9 <br /> l Arm # E Land Use Application # <br /> BOS Dist Location Code _:A <br /> r.ONTRACTOR and/or 1 <br /> SFRVir.E RF.oUESTORI �rI�1 �) BILLING PARTY Y / N <br /> 1, <br /> DBA PHONE #1 (_110 <br /> MAILING, ADDRESS 4,01' Q 1/U/��1/I l�O Iit.l T , � `N✓ FAX # ( r2`D )GI J n/"—_�- <br /> CITY �o/�Q.i V1 I/l.� /�- STATE r-A-_ ZIP �D <br /> RII.LING ACKNOWLEDGEMENT! 1, the undersigned owner, operator or agent of same, acknowledge that all e e or.:pro]ect specific <br /> PNS/END hourly charges associated with this facility or activity will be billed to the party Id ifSeEl i eIBiLLiNG PARTY on <br /> PngA 1 of this form. Ei , <br /> i n15o certify that i have prepared thi—application and that the work to be performed will be do►ie in lc2or" with all SAN <br /> JOAQUIN COUNTY Ordinance C s a S ndards, St Fed al la SAN JOAQUIN CO"LINTY <br /> PUBLIC HEALTH Sr..Pti C:~S <br /> APPLICANT'S SIGNATURE ENViRONMEN,rALN'E" 1 'E%Iwl`'io�"1 <br /> Title. t <br /> Date: <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 aite address hereby authorize the release of any and all results, geotechnical data and/or <br /> Pivirormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> It is available and at the some time it is provided to me or my representative. <br /> Nnture of Service Request: Guice Code __:r �� <br /> � �\ <br /> ASSigrxd to R 3 W \ Employee If <br /> Date Service Completed / / Further Action Required: Y / H [PROGRAM ELEMENT ate: k; Q <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> RFHS _/ / SUPV _/__/ ACCT I I/ /, UNIT CLK _/ / <br />