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+, SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # 00 3 z J RECORD ID # )6 9 INVOICE # <br /> FACILITY NAME Tc—,X u d BILLING PARTY Y / <br /> SITE ADDRESS "40 L4-' 4 al <br /> CITY STOC, �r t0 �1 CA ZIP S`2-06 <br /> OWNER/OPERATOR f 40 ` V' o 4 d BILLING PARTY Y / EN ] <br /> DBA Cu ( rig x- G O PHONE #1 (2�)_� 3 3 1 Z <br /> ADDRESS T V W 4 Q r I u PHONE #2 ( ) <br /> CITY _7 �O G !� L h STATE C�f ZIP 7 S_ZQ <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR / G�f dJ L11— 4- a BILLING PARTY / N <br /> DBA 1� CC u til S !/� G� S CO PHONE #1 (r10 ) <br /> / P 6�.1 76 <br /> MAILING ADDRESS 2-1 .i-6- ✓!t LO1 � C� FAX # ( �!o ) 2�-7 g3`Tz <br /> CITY CO S b-0 V-4 �1 �Y STATE C c,, ZIP q (+-4--4 <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 UaGWXYied as the BILLING PARTY on <br /> Page 1 of this form. TT ����11 nn <br /> RECEIVE <br /> I also certify that I have prepared this application and that the work to be performeak .I� ti� d n accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. 1111 IJIN COUNTY <br /> SANJOAQ <br /> �� PUBLIC HEALTH SERVICES <br /> APPLICANT'S SIGNATURE rnTAI H-I- DIVISION <br /> Title: 6,40 k? S Date: 31 3 Z 9S— <br /> / I <br /> AUTHORIZATION <br /> S— <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: ��.�C/w� �1� F Service Code <br /> '\ v <br /> Assigned to Employee # Q b Date 3 d 's /� <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment ype Receipt # Check # Recvd By <br /> Z /3 CI,�- IJ <br /> REHS / / SUPV _/ / ACCT / / UNIT CLK _/ / <br />