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IDA•NL "��?6 ` Sum �"'�"0'"� �y.320 --6v 74 <br /> (0-0 _t Wb61!WpakJ <br /> SERVICE REQUEST /4 <br /> S <br /> FACILITY ID B RECORD ID B p0 INVOICE B 0o'l of <br /> FACILITY NAMEDNE ,(� l -E'1 D, <br /> — BILLING PARTY Y /Q <br /> SITE ADSS _ —7 3cQ /t/`�`''•'Pao 4a- <br /> CITY <br /> CITY C1 ZIP <br /> .9.`+v-L>�i'l�'fd/-c,-.— � S <br /> OWNER/OPERATOR C' ✓ �""'� BILLING PARTY Y / M� <br /> ou PHONE 61 <br /> ADDRESS i -I S� _ !L/�G'^tiDO�. i' PHONE n <br /> CITY _ STATE ZIP <br /> APN LarUAplicatioB <br /> Location Code <br /> J <br /> G1 <br /> Cr- <br /> CONTRACTOR <br /> J <br /> SERVICE REQUEST; �(�� G �/- ""\ BILLING PARTY <br /> DBA _ PHONE 01 <br /> MAILING ADDRESS ,1�� �(/JCl N�^�/�l ( � C FAX Ali <br /> CITY ` STATE X- ZIP ! G� <br /> BILLING ACKIIOMLEIGENENT: 1, the udersigrmd owner, operator or agent of saes, ackrowtedge that ell Site ad/ot prOJact specific <br /> PRS/EHD hourly charges associated with this faculty or Activity will be billed to the party identified as the BILLING PARTY on <br /> Page I of this foie. PAYMENT <br /> pC�r.••�n <br /> 1 also certify that I he 'a eppli ti and th t the i to be perf will be dorm, in acCordsnee with ail SAN <br /> JOAOUIM COUNTY Ordi Codes St S to and Fed el to . _ APR 2 g 1996 <br /> SAN JOAOUIN COuN t r <br /> APPLICANT'S SIGMA <br /> Title: Date: tRONMENTAL HEALTH DIVISION <br /> r Jae <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the oNrm-, operator or agent of sees, of <br /> the property located at the Above site addrege hereby authorize the release of any end oil raautts, geotecMical data rd/or <br /> arwirorgental/site eseeesaent inlorestion to SAN JOAQUIN CO)NTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION As soon As <br /> it is available and at the Bss ties it Is provided to se w my representative. <br /> Nature of Service Re¢e,t: Service Cale <br /> Assigned to1 1 �C%� Date ��7�/ Le <br /> Date Service COAlpletd �/ 7 / _ rt Actlon Required: Y /i�y PROGPAM ELEMENT Z <br /> Fee AwJ t Anent Paid Date of Payment PaymentType Receipt B Check M Rocvd By <br /> MS __/_/_ SPv _/_.,_ ACCT LY'/ UNIT CLK <br />