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SERVICE REQUEST (SERVREO) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # /-! <br /> INVOICE # <br /> FACILITY NAME NTXD'fI A0&b/y 4ygP0LI-r BILLING PARTY Y / <br /> SITE ADDRESS _/'178/ E, L/L-67 0,f.4t 2r� <br /> CITY /--07,) / CA ZIP <br /> OWNER/OPERATOR C-64-s 4) v- N/)c „/ BILLING PARTY 67 N <br /> DBA PHONE #1 ( Z Z)�' 173 <br /> ADDRESS y`/3 LC<)Y✓w2� �l/� PHONE #2 ( ) <br /> CITY "^ ?',5r4 STATE C.4 ZIP -15-734 <br /> I—APN # Lend Use Application # <br /> OGS- 29v -/y �/YI S �/�/— / BOS Dist Location Code <br /> CONTRACTOR and/or ^ <br /> RFRVICF. REDUESTOR NEIL- O, A_Z9,5Zr &,,, •=r/C , BILLING PARTY Y / N <br /> DBA PHONE #1 (209 ) 7.17 - 370/ <br /> MAILING ADDRESS ZZ /V. /401/57-01V Lam/ FAX # ( 20`) ) 313 - k3o3 <br /> CITY L-0D/ STATE C1- ZIP 9 SZ '16 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> PAYMENT <br /> 1 also certify that 1 have prepared this application and that the work to be performed will be done in accRe6L011VL9 1gAN <br /> JOAQUIN COUNTY Ordinance Codes and tandards, State and Federal laws. MAR 2 O 1995 <br /> APPLICANT'S SIGNATURE D SAN JOAQUIN COUNTY <br /> Z ENVIRONMENTAL HEALTH DIVISION <br /> Title: � S//7� <br /> 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, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: �5 ! (' � Service Code <br /> Assigned to Employee # �6 �- `iF" Date 3 / 7 In_1//�-1 <br /> Date Service Completed 4 /2 Further Action Required: Y / (� PROGRAM ELEMENT ala(p�oC <br /> Fee Amount Amount Plaid Date of Payment Payment Type Receipt # (Check # Recvd By <br /> LSVV <br /> RENS _/ / SUPV _/ / ACCT / / UNIT CLK `/ / <br />