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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # 0 o Ap '�5 RECORD ID # �, INVOICE # <br /> FACILITY NAME 0o y�l! I BILLING PARTY Y /SITEADDRESS <br /> 0 <br /> CITY, C CA ZIP r <br /> OWNER/OPERATOR OACC pn 0 rh C �/ BILLING PARTY Y <br /> DBA PHONE #1 <br /> ADDRESS / X SC/Ulk" PHONE #2 <br /> CITY � STATE C6! ZIP <br /> APN # Land Use Application # <br /> IFBOS Dist Location Code <br /> CONTRACTOR and/or � hL � C07 <br /> 22��/ / �� <br /> SERVICE REQUESTOR _ <br /> � FBI <br /> LLING PARTY Y / N <br /> DBA PHONE #1 (C&�D9) - <br /> MAILING ADDRESS J C FAX # <br /> CITY v JG�( 0 / STATE ZIP (?15�9q 22 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledgpAIAA F ite and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity wilt be billed to the pEptFerdentified as the BILLING PARTY on <br /> Page 1 of this form. <br /> J U L ► 1 1998 <br /> 1 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. oi.r: r-:(jiN�.UUNiY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPLICANT'S <br /> SIGNATURE : <br /> Title: ► ��^ /� v Y Date: 30 R <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 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: <br /> Service Code ' <br /> Assigned to <br /> M�c"a h., 1 v e Employee # 04 r/ Date / / 10 / C� <br /> Date Service Completed —/—/ Further Action Required: Y / N PROGRAM ELEMENT • �)v <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 7� <br /> 77( Az <br /> REHSjy / / SUPV _/ / ACCT _/ /_ —TU NIT CLK _/ / <br />