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SERVICE REQUEST (EH 00 61) Revised 0/23/93 <br /> rACILI/Y ID 0 2a.i RECORD 10 0 al 60 NVOICE N <br /> FACILITY NAME <�j/�C. �)�'��5J1�Cr r�ie CA�Z +r 7e � BILLING PARTY Y <br /> SITE ADDRESS / �� Y+/• `�/7 � �y��'y� �G <br /> CITY 1�dc�/ ZIP <br /> OWNER/OPERATOR �! / e-- BILLING PARTY Y /� <br /> ORA / PHONE N1 ( ) <br /> ADDRESS 'r 7�� 1� ,Aez-le- "'i PHONE 02 ( ) <br /> CITY STATE ZIP gS37� <br /> APB N - - Lend Use Appl icat lam (I <br /> DOS Dist Location Code <br /> CONTRACTOR nrd/or <br /> SERVICE RFOUESTOR ,1�r/./l>//J J ���� BILLING PARTY I / N <br /> Dea /�l t/@i/% � �SL�7 StOL/07e5 PHONE X1 ( > <br /> MAILING ADDRESS �_� C�Of!/c�rJOZI� � FAX a t ) <br /> CITY n.%�T�� STATE / _ ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the Undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PIIS/EBD hourly charges associated with this facility or activity wilt be billed to the party identified on the BILLING PARTY on <br /> Page 1 of this form. <br /> ,I also certify that I have prepared this application aid that the work to be performed will be done in pPsAp $[5?' n all SAN <br /> JOAOUIN COUNTY Ordinance Codes Standards, State and Federal Inws. 1'LG E�� <br /> APPLICANT'S SIGNATURE :�/ G i r�aL ..$$OCT 2 3'1997 <br /> AN^ � li� /t P�DBLIC HEA TH SERVICES <br /> I <br /> Title:_ <br /> �' _�� �17�1rlE�"i/ Date: TAL HEALTH DIVISION <br /> �_ <br /> AUIIIOR17ATION 10 RELEASE INFORMATION: In ncklitlon to the above, wbmi applicable, 1, the owner, operator or agent of some, of <br /> the praperty located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envjrorncntal/site assessment Information to SAN JOAIXIIN COUNTY NHILIC HEALTH SERVICES ENVIRONMENTAL H <br /> It is avnitabte and at the sane time it is provided to me or my representative. iy--J -'1 -7 (oo <br /> Nature of Service Reorient! SL2 -U A �. Service Code l � <br /> tl <br /> Assigned to © Z Employee IF 1� Date 1 /� . <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT d- L <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt N Check AT Recvd By <br /> / Z,3oI SUPV I _/ /__ ACCI —/_/_ UNIT CLK _/ /_ <br />