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�. <br /> SERVICE REQUEST <br /> ' CEN OO.61D Revised 8/23/43 `.;. <br /> - <br /> FAC%CITY ID #:_ RECORD. ID # ' :INVOICE it., <br /> FACILITY. <br /> >w <br /> Y. <br /> BILLING.PARTY-. <br /> ® . <br /> SITE ADDRESS W <br /> CITY CA ZIP .�Z-�� <br /> 01dNER/OPERATOR;! 05Cb 'MAS- It:1 BILLING PARTY . Y. • / N <br /> DBA F (.�ri�L�P� F PHONE *1 <br /> ADDRESS J& TJ �cD�ll�b� PHONE 02 C - <br /> CITY ' � C4 r-5 10 STATE. ZIP <br /> APN 0Land Use.Apptication a@ <br /> Dist' Location Code <br /> CONTRACTOR and/ , <br /> -- <br /> SERVICE REQUESTOR. S- BILLING-PARTY <br /> _ Dom► r ' 'T® s ;PHONE #1"(: ; <br /> NAILING ADDRESS (� y '�IT 1�G •^ FAX; <br /> CITY STATE ZIP t <br /> BELLINQ t GEMENT - I,kthe undersigned owner; operator or agent of saw, ackimeaieclge that'alt.site,aiid/or°'j oJect.specific <br /> PNS/EHD_hourty charges associated with th$s.facitity or acti4ity wi U-be, bitted to the party`idmtifiad as.the BILLING PARTY," <br /> Page 1 of:this form T F} _ f ' <br /> 4. <br /> B also certify that I have prepared this epplication`anci that the:work to, performed wit 1:66' iniaccordancs with-att SAN <br /> JOAQUEN COIfliTY Ordinance Codes" '§�an�rds; State' F l fairs t t <br /> APPLICANTS SIGNATURE:. _ <br /> Titleate ? , r s' i <br /> •AUTHORIZATION TO RELEASE• INFORMATION In addition to the above,.when apptIcabte;' I, the owner;:operstor oe agent of-same;"'of <br /> the poperty located et,the above site aidress'h®seby;authoPiae the release of. y:arid=all results, geotechnfcat data and/or <br /> environ ntat/site'assessment.infor tion to.SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION`-es Soonas <br /> It is.avaitabte and at the sme time itis provided to 6, or my representative. - <br /> Nature -of Service Recy�st: Service Code <br /> Assigned tto' <br /> - Edployee ,� DateJ <br /> t Date Service Canptetad Y �.•,.! `• / • ' Fta�ther Actiat Regttired: Y :'/ N PROGRAM ELEMENT x <br /> ;.. ,y.. Vis•,+.__ a x°"t!' <br /> J Y 1 :..?7. - '.M- id. - S K XGT` /f .sI •:nY. . ..tt..w.<¢_ f6'6 _ b. � ' � <br /> •^...J`- ^.ST«".'r.:Tw J'1: }`.}•:r:' .: �rt: :"ce,:•• :r "^`..4.. 17''i'... <br /> Fee,Amount ' Amount Paid Data of P J P t'T- a` Recei t f# t 'j Check <br /> ,= y4- �. rf•. ?s r ti41 a 1r ,� �.-„LY! 3 2 Yti ..� ` ti:-••t tdS, ri -rte. <br /> 3�+••Y C;: '� � '? M1r t1.. (•x �'}'.•�' �' J ,� `.}o -�% ,.rv- �i..f e.`r. �4ti. •x. r•� <br /> 'Z f <br /> REHS _/' • _. ./; SUPV _/_''f ACCT..'-*, <br /> �. . <br />