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SERVICE RCQUEST (EH 00 61) Revised 8/23/93 <br /> -- - <br /> c <br /> FACILITY ID # RECORD ID # 1 �I (D-� INVOICE # <br /> FACILITY VAMCLONE Uk� VINE Pr 24 3 LiAG PARTY Y / ^ N <br /> SITE ADDRESS C- kaV- /1�_Lavye _ - <br /> CITY LOi7l CA ZIP <br /> OWNER/OPERATOR IV4NcY HAMMWO -T BILLING PARTY -Y -/-- <br /> DSA PHONE #1 <br /> ADDRESS )-1150 t5- 14 AZ W C, LAtJE PHONE #2 <br /> II ( ) <br /> CITY WD„L STATE C-A__ ZIP _152.4 <br /> APN # ; Land Use Application <br /> 5 128 - j (, 0o dist j ` Location Code <br /> CONTRACTOR and/or --- - - <br /> SERVICE REQUESTOR , y��I t��-y�� (-�5 �� BILLING PARTY Y / N <br /> DBA PHOPE #1 C _) <br /> MAILING ADDRESS " j() jN L 4�- <br /> FAX It (,M 0-30-3 <br /> CITY (�_on1 STATE _ ZIP -/ 5ZTO <br /> PAYMENT <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that alt site and/or pro ect specific <br /> PHS/EFD hourly charges associated with this facility or activity will be billed to the party identified as th@ EIPLl GOIA]99an. <br /> Page 1 of this form. �7 <br /> SAN JOAQUIN COUNTY <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accorENW-ICIdE't°tLTbIL3E5=ES <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federat laws. ENVIRONMENTAL HEALTH DIVISION <br /> APPLICANT'S SIGNATURE 1 �. ()� Vjc-LmEN SINIJCLK � NF-Joa4 0 Iloc . <br /> Title: Date- <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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, eeotechnicat data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PU3LIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or iry representative. <br /> Nature of Service Request: Service Code <br /> Assigned to Employee # Date <br /> i <br /> a <br /> Date Service Completed /2 / Further Action Required: Y , PROGRAM ELEMENT• ZV <br /> i <br /> `Fee Amount Amount Paid I Cate of Payment Payment Type .I Receipt # Check # Recvd 3y <br /> REHS i / / f SUPV 1 _/_`/ i ACCT _/ / 1 UNIT CLK _/ / <br />