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6-Ud-1998 1 :26PM FRUA F_ <br /> SERVICE REQUEST (EN 00 61) Revised 8/23/93 <br /> INVOICE M <br /> FAC11.1" IDR VI '> L RECORD IDP l <br /> FACILITY NAME 4-1 ujT BILLING PARTY Y / <br /> SITE ADDRESS lot �i (7 1 C- 1_(✓ ( - J-;X-, <br /> CITY CA ZIP -I _— <br /> OWNER/OPERATOR �O V�_1�1C1 ��.1 .� SILLING PARTY 7 Y / U <br /> �. DBA PHONE 81 (j 1 O)_735 15CJ:� <br /> ADDRESS PHONE 02 ( ) <br /> CITY -1 VL Z— STATE 'f' _ ZIP <br /> F <br /> APN p Land Use Application 0 <br /> BOS Diat Lace an Code <br /> CONTRACTOR and/or \/ <br /> SERVICE REQMSTOORR �5F`^ 1�CC��j� `�-�T(Cy��\ (YI 5 75/}�C CnS,�/—{�fSJ1�� - BILLING PIUtTT �7 C / H <br /> DBS✓JFy 1���J 1�^ : �V �l� �� �Y' �_� 1/Y Ili PHONE N1 (�) I ( <br /> NAILING ADDRESS 1�✓W N. f 1 { , _ J > Y C �/� FAX 0 ( o0 ! ' -0135 - <br /> CITY STATE `/+ + ZIP =! ) I <br /> i <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of sane, 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 81LMt ff� <br /> page 1 of this form. �� uuvVEeI�GI/�YY <br /> .f <br /> 1 also certify that 1 have prepared this application and that the work to be performed will be done in accordanc.�LNh at T98 <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and federal laws. �eJJ�uJ�I��J I� <br /> SAN JOAQUIN COUNTY <br /> APPLICANT'S SIGNATURE rH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Title: \,���-� C1�;rX:c�.,_�Y Date: l� / �� <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 /> envirorniental/site aesesamant information to SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided tomeor my representative. <br /> I Pie Nature of Service Request: <br /> f (/lA Service Code L4 <br /> / <br /> Assigned to Il 1a t 1 Lj i Eaployee N V ( V Date l L <br /> Date Service Completed _J_� Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt k Check 0 Recvd By <br /> RENS J / SUPV _�_� ACCT __/ / UNIT CLK _/_/ <br />