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01-1.-1996 09•JJAf1 FROM TO 15108958426 P.02 <br /> SERVICE REQUEST <br /> (EN 00 61) Revised 8/23/93 <br /> FACiLitT ID # RECORD ID # INVOICE # <br /> FACILITY NAME 'Iii (o C�' BILLING PARTY Y / N <br /> $I TE ADDRESS <br /> CITY ��(� CA ZIP <br /> OWNER/OPERATOR �Q �O <" C � �_6 d"\tihy-L\� BILLING PARTY Y / CN <br /> DBA PHONE #1 ( IWl )�.t Sia <br /> ADDRESS PHONE #2 <br /> CITY �C� �7�\_ \ STATE CA" ZIP D17> 1 <br /> APN # I Land Use Application # <br /> SOS Dist Location Code <br /> i <br /> CONTRACTOR and/or r <br /> SERVICE REQUESTOR Lb BILLING PARTY / N <br /> I <br /> DBA PHONE #1 ( 5(d <br /> MAILING ADDRESS I�^l\� ��>o����\ �' FAX # Lf <br /> CITY STATE ZIP S 7 <br /> BILLING ACKNOWLEDGEMENTt 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 rrive prepared is cation end that the xork to be pe will be done ir � l�th all SAN <br /> JMQUiN COUNTY Ordinandr Codes a St to and Federal laws. R E�E��►` ' <br /> APPLICANT'S SIGNATURE :I �, OV 2 1998 <br /> Title: ��U G Date Q_ SAN JOAL)ULN COUNTY <br /> pygHG WEALTH SERVICES <br /> U ENVIRONMENTAL HEALTH DIVISION <br /> AUTHORIZATION TO RELEASE INFORMATION! In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located *tithe above site address hereby authorixe the release of any and all results, peotechnieal data and/or <br /> environmental/site assessment information to SAN JOACUIN 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 /> i <br /> Nature of Service Request: Service Code <br /> Assigned to Eaployee # 6;, h Date <br /> Date Service Completed) / / Further Action Required: Y / N PROGRAM ELEMENT _Z 3• +a' __ <br /> I <br /> Fee Amount Arno�nt Paid Date of Payment Payment Type Receipt ft Check 9 Recvd By <br /> I <br /> f L <br /> 1 <br /> REHS <br /> SUPV ACCT _� / UNIT CLK <br /> I <br />