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L SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # mis I I RECORD ID # <br /> S INVOICE # 04f-1 5r <br /> FACILITY NAME -E3:2-Q 2R11.1:i T�Qimt BILLING PARTY' Y / d <br /> II C�- <br /> SITE ADDRESSYA. •l Sat __ Nolm- PARCH MAP DATA <br /> (ESCnk.,g5f4) r-:RArIK -V. BCPSA <br /> CA zip 95-520 23, �. Do1�0`5-R,--,qD <br /> KoFEPr' AmeEzS ; IC-144-9 4E. SK.i� �.y �SCA Lc�N ESc'A�N,C^ <br /> OWNER/QPERATQR46AC2i~ BILLING PARTY Y <br /> DBA PHONE #1 ( ) <br /> 51�£ `, �A 2 <br /> a C ADDRES 5 `t 1� 2�AG PHONE 92 ( ) } <br /> CITY �<Z A 1-.n N STATE C_ ZIP <br /> APN # Land Use Application # <br /> E =BOSDilt <br /> Location Code <br /> t <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR : AI--EER Cl i R"T 15 BILLING PARTY q/ M <br /> DBA L =- i Y I � j4IE�Q- PHONE #1 (21:59 )L4 <br /> _- -1 S <br /> I r <br /> MAILING ADDRESS X4.18 MA7—T��v,! PL ai1� _ _._ FAX <br /> CITY LCDq STATE _ zip 9SZ4—c� I <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> i <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 I of this form, f <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. PAYMENT <br /> APPLICANT'S SIGNATURE RECEIx"EID <br /> Title- Date: $—��� 4 '� All 291997 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, eperatorsAlr W04 t1�b� sof <br /> PU C:_ -ALT . <br /> � <br /> the property located at the above site address hereby authorize the release of any and all results,EM9ALplL <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: Sc>(L SQ k-rNakL:%T-! SSrUb-(l[� �PCT1G`�L � Service Code a` <br /> 'W=�NEs�HY, �-a�.9? 13i�►,� R'3=nr �p�•+ P.��.D;HG, � <br /> 12 3 <br /> Assigned torlv -EnQl�ee # _ ���Z�. _ Date <br /> Date Service Completed Action Requited: T =NPROGRAM ELEMENT <br /> 1 <br /> Fee Amount Amount Paid , Date of Payment Paymen Type Receipt # Check # Recvd By <br /> f <br /> "S / / SUPV _/_� ACCT �/ 3 �� UNIT LLK <br /> i <br />