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FACILITY ID # I <br />SERVICE REQUEST <br />RECORD ID # I 0///?l <br />(EH 00 61) Revised 8/23/93 <br />INVOICE # I 0_344 <br />, <br />FACILITY NAME S%GL�TTJ=� /�-C�2� BILLING PARTY <br />SITE ADDRESS <br />CITY <br />OWNER6ERATO <br />DBA <br />ADDRESS <br />V <br />CA ZIP <br />BILLING PARTY Y / N <br />PHONE #1 <br />PHONE #2 (_)-- <br />CITY <br />) <br />CITY STATE ZIP <br />APN # Land Use Application # <br />BOS Dist Location Code <br />CONTRACTOR nd/or <br />QUESTORO "�� ;��I/�'—"" BILLING PARTY Y / <br />DBA PHONE #1 O <br />MAILING ADDRESS 1`'2v FAX <br />CITSTATE 4!�� _ ZIP <br />BILLING ACKNOWLEDGEMENT: I, 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 p e ed is app icatia-rand that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance C e and ndards, State and Federal laws. <br />APPLICANT'S SIGNATURE : - -- 41996 <br />Title:- <br />- <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: VVh <br />Assigned to f Q <br />Date Service Completed <br />Employee # 0 O (:) y. <br />Further Action Required: Y / N <br />ice Code 19 F, <br />Dates <br />PROGRAM ELEMENT ;Z, 3 O 9 <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # Recvd By <br />REHS C/ SUPV _/ / ACCT/ D /. I� UNIT CLK _/ / <br />