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10 <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID RECORD ID # O/ a r INVOICE # <br /> FACILITY NAME N�1(//� —`� � �1�� 7 16N BILLING PARTY I Y / ( ►+ J <br /> SITE ADDRESS /G / / 5 <br /> CITY `� — - CA ZIP <br /> OWNER/OPERATOR D�/ /"�i�" �" vy BILLING PARTY Y / <br /> DBA PHONE #1 ( ) <br /> ADDRESS f 4 �' ° �G K/( ���(� Qom` PHONE #2 ( ) <br /> AF <br /> CITY <br /> STATE ZIP I7s/C ' <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> N <br /> SERVICE REQUESTOR <br /> DBA <br /> PHONE #1 <br /> MAILING ADDRESS FAX # ( 4�s ) 3¢7' Sq7 1 <br /> CITY u2�'`�`�� � STATE Ce ZIP <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 the party identified as the BILLING PARTY on <br /> Page 1 of this form. PAYMENT <br /> I also certify that 1 have prepared this application and that the work to be performed will be di�`ie with all SAN <br /> JOAQUIN COUNTY Ordinance C es Standards Stat a delal taus. <br /> APPLICANT'S SIGNATURE <br /> JUL 31 1997 . <br /> — 2 SAN JOAQUIN COUNTY <br /> Title- G� �+'I Date PUBUCHFALTHSER;ICFS <br /> ' '�' �CiE1�FF;LiTEALTHOMSIOW <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of some, 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: aService Code (_ / <br /> Assigned to J�^hami �SU� Employee # �yU Date /_ L/ �7 <br /> Date Service Completed / _/ Further Action Required: Y / N [PROGRAM ELEMENT J V <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> Ly <br /> __/ / ACCT '4" ,e -7 <br />