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SERVICE REDDEST (SERVREO) Revised 8/23/93 <br /> � <br /> FACILITY ID # RECORD ID # INVOICE # (Q <br /> FACILITY NAME <br /> SITE ADDRESS 30 3 Z-7 Pl"Ma ft-f �70 <br /> CITY /¢SC fL-- 4 CA ZIP <br /> BILLING PARTY /N / N <br /> r KJELDSFAJ- PHONE #1 9 ) -/y6 0268 <br /> W.? W 7- PHONE #2 ( ) <br /> STO Ltk—TOJI-j STATE CA- ZIP 9S'Zo3 <br /> EAPN # Lard Use Application # <br /> 221 -176)- 'Z-1 �`Y/S qy_3 5 BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REDUESTOR 14e� o. A/-/NOE/GSo/ BILLING PARTY Y / t� <br /> DBA /Or-1, �• /7N4Fi�t✓-r G /7S�rK. �N�. PHONE #1 (Z�_) 3� 7 - 3;70/ <br /> n! t 2�5 ) 333 - ?3°3 <br /> MAILING ADDRESS ZZ /'O✓STD../ Lf/ FAX # <br /> CITY LO/) / STATE GA ZIP VP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD 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 /> I also certify that I have prepared this application and that the work to be performed will be time in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, Sta Federal laws. PAYMp�FYiC'::: .- <br /> APPLICANT'S SIGNATURE U' // ° <br /> Title: ��-GS�/Oe. 7 Date: / / , /'J5— FEB 17 <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 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 ServiI c�e'Request: <br /> � (` •� fService Code _ <br /> Assigned to Employee # tp'3-.L Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT h 7- <br /> Fee <br /> Fee Amount AmountPaid Date of Payment Payment Type Receipt # Check # Recvd By <br /> I 5 1, mo�KJ•CD - <br /> RENS _/ / SUPV _/ / ACCT UNIT UNIT CLK / / ' <br />