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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # <br /> FACILITY NAME LU t 7?> BILLING PARTY Y / <br /> I f)G -?. PM I� 51 <br /> 1. <br /> SITE ADDRESS Z��pR ��r,vC,�Yv.�� t� <br /> CITY S1008r1 CA ZIP CV;J0 A <br /> OWNER/OPERATOR �� c�vy� �S �`a�,-_Q_ BILLING PARTY Y <br /> DBA i (l C-V PHONE #1 ( Zc" ) �1 SSS�1Z <br /> ADDRESS h K �U\f�� �� AL1 PHONE #2 1,k <br /> CITY �(.� ���, VY)t\, STATE S V ZIP \0 L� <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR C-O A BILLING PARTY (ny / N <br /> D13A `(l�� C C SC�� PHONE #1 (S W ) <br /> MAILING ADDRESS L� �� /yt� \�� \\fyc FAX # ( S\O <br /> CITY �C�y� �rV'Irb STATE �� ZIP LAS <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. <br /> I also certify that I hav4-P7-e ared this , plica ion and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY OrdinanCe`Codes and d to ads, State and Federal laws. <br /> �J ti <br /> • APPLICANT'S SIGNATURE <br /> Title: 4\Q,\(0 nosyy(1 Cp Date: <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: r r�7' Service Code / <br /> Assigned to Employee # Date _/ <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT 7 • <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 417- <br /> q <br /> / <br /> RENS _/ / SUPV _/ / ACCT __ /�/ UNIT CLK _/ / <br />