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B-12-1997 3 : 05PM FPU,-1 � P: <br />1 <br />SERVICE REQUEST e , <br />FACILITY ID # RECORD ID # i'l 7 INVOICE # D q1 -7-7 <br />-7-7 G <br />FACILITY NAME _ <br />/ 5 7 7/0,4 <br />STATE <br />ZIP ! 7 J <br />BILLING PARTY Y / <br />- Land Use Application # - <br />SITE ADDRESS <br />�.— /Y <br />I%i/1i(�� <br />� ,� /J/U <br />r. <br />CITY �-%� ���%[�/v CA Zip— 95724 <br />OWNER/OPERATOR =2jco /•/h/�I� ����? C {� <br />DBA <br />BILLING PARTY <br />PHONE #1 ( ) <br />Y / <br />ADDRESS 'LCL O CJ2VAN�� pL� # -f PHONE #2 z %% - ZY <br />CITY <br />5 119 AJ L4 )9 M ON <br />STATE <br />ZIP ! 7 J <br />AP14 # <br />- Land Use Application # - <br />$OS Dist <br />Location Code <br />CONTRACTOR aril/or <br />SERVICE PEOUESTOR <br />- <br />CAZ�Fb(fN119 <br />6e&/�_5 <br />/�%� BILLING PARTY / Y ,/ / N <br />�v <br />DBA <br />��� <br />PHONE #1 (%/4 )y.y��-"� <br />MAILING ADDRESS <br />�7�, Cj / r /91y, 0,eelt <br />Y r <br />FAX # ( /_� 9q9 0 <br />CITY X541" <br />T/CJ dA14 <br />STATE _ <br />ZIP 2. '5 <br />myM E NT <br />BILLING ACKNOWLEDGEMENT. 1, the Undersigned owner, operator or agent of some, acknowledge that a p rMFUR project specific <br />PHS/EHD hourly charges associated with this facility or activity will be billed to the party identifiec}� g�iLLING PARTY on <br />SEPPage 1 of this form. SEP9 <br />I also certify that I have prepared this application and that the work to be performed will be ONCtE�ft"j'ith all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and//Federat jaws. ENVIRONMENTAL HEALTH DIVISION <br />APPLICANT'S SIGNATURE : <br />Title' QIee___ISale •/'�r �. Dnt,,. 2//(,/e-/ % <br />y <br />AUTHORIZATION 70 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 />envirorwnentol/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION OK, <br />soon as <br />it is available and at the same time it is provided to me or n,y representative. 0 K, / <br />Nature of Service Request: <br />'D V <br />Assigned to /'1� Enployee # <br />Date Service Completed _/ _1 Further Action Required: Y / N <br />Fee AMCKTIt I Amount Paid I Wte of Payment I Payment Type I Recei <br />Service Code <br />Date,/_/� <br />PROGRAM ELEMENT 6'2= <br />Check # I Recvd By <br />