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<br /> SERVICE REQUEST _,SMEW
<br /> FACILITY ID # RECORD ID # 11NOICE it.
<br /> •S
<br /> 7 FACILITY HAMS 2 C ti L C "'� .tL1►� G PARTY"= r. N
<br /> . y INV #
<br /> SITE ADDRESS S
<br /> CT F"
<br /> i CITY ZIP - % S^3 7�' 4t , '•
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<br /> OWNER/OPERATOR T�9C 3 Y StLLING PARM,
<br /> DBA _ PRONE #1 iA36
<br /> f ADDRESS �1 � T,P.4� y �5L 11 r4 PHONE #z ( ) Lha y.
<br /> CITY ?_ G1� STATE ZIP
<br /> AP"
<br /> # Land Use Application # t F
<br /> .=a 805 Dist .Y Location Cade `
<br /> CONTRACTOR and/or :.' r
<br /> r ..SERVICE REQUESTOR G{'R.CG-/'fT f"'rVVrRDIVME/UTiS�'� SEJQI�T•LGS �. BILLING
<br /> PARTY Y ©y '
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<br /> PPONE.
<br /> #1
<br /> MAILING ADDRESS i l�y W�t FAX
<br /> CITY t/ STATE IIP 9I5-74
<br /> BILLING ACKNOWLEDGEMENT:,".'-I the undersigned owner, � � �
<br /> g , operator or agent of same;acknowledge that all siterand/or project specific= {
<br /> $ PHS/EHD hourly dtarges associated with this facility or activity will.be bitted to the party identified as the BILLING'PARTY
<br /> rt Page 1"of.this'farm, -p - 'r- -♦ �i�-. r ,
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<br /> I also certify thi t`I have-prepared this application and that the work to be performed wiLL-be done-in accordance with aWSANc� �
<br /> JOAQUIH COURT y0rdinance Codes Standards,,. ate and Federal Eaves -rYr ., r f"
<br /> ,F.= �.r -r!w• max_ � -�>''� +lr.� ;4"as
<br /> APPLICANT'S SIGNATURE ' S
<br /> -y'kaf.-�y-'.^i15 pr'aZ-1
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<br /> a {, AUTIlORIZATION TO RELEASE INFORMATiOH in additiat W the above, ti+iten aiipEicabEe, I, the otiner,:,operatw. ar agent`of
<br /> p. a t r: stdN .ate
<br /> the property tocated at the above site address'herety authorZze the release of arty and aLI results, geotechnicaE�data ar>�or spa
<br /> - r aa•_ -4 .. sr'-7sv_.+' -. wF-T•S
<br /> _ environmental/site assessment information to SAN-JOMIN COUNTY-PUBLIC;HEALTN:SERV ICES ENVIRONMENTAL,THEALTH DIVISION as soar SSI%%
<br /> _ «.. .�. i' .pG-:- +., ,�'t •k�x.-'^' w 4 nam"° LTH: '�'
<br /> 3 S ,. ) �.•- - z. -r i vt T".+,fit- S�°` se. Ef"
<br /> it is' avail'ablb and.at the same ti it is provided to-me or my representsetve � k
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<br /> «"° a `t5`iiNature of Service Request US E� �� :� � Ksvitx Coder j4s 'V`'° �tovee # [� j ; _° `aa-7s + � PROGRAM EL.EltENT 'Date Service CampteFurther Action Required YLL$t /r'N ` 7.�ti.
<br /> Fee Amount Amount'Paid s,Dat@"of PaymentPay+nerityTypeRecespt $ Checic # ;— Resvd ByO;2 h /a 4! F"R 9 //�••`^i "r tr4j'Y' {,3
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<br /> REH5 / / si3PY Jam'` = ACCT / J UNIT:CLK le " x' •F s
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