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0 SERVICE REQUEST 0 (EH 00 61) Revised 8/23/93 <br />FACILITY ID # 6-0 <br />RECORD ID #Olo V71 INVOICE # <br />FACILITY NAME GD &4 4 4— BILLING PARTY Y / N <br />SITE ADDRESS f �7'T�TLG Aj e A -r, ' <br />CITY .SC�fuV� CA ZIP �7SZ.c7� <br />OWNER/OPERATOR/-Il^�/�!y AZT BILLING PARTYY / N <br />DBA PHONE #1 (.Zd 1 ) 1/—V - /,.V <br />ADDRESS 6P.►'1 9(7 PHONE #2 ( ) <br />CITY S STATE ZIP y -z ( /. <br />APN # E Land Use Application # <br />BOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR f j' (4 —n S G6 BILLING PARTY Y / N <br />DBA onrv.Q� 7Y�f ��� PHONE #1 (�i (�) "��'^t -�5► Z <br />MAILING ADDRESS 111 USG �'3rJ� ��l 7' FAX # ( ) <br />CITY S—Ar�� tz� STATE 7 ZIP <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that at( site and/or project specific <br />PNS/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 />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. lam(/ <br />APPLICANT'S SIGNATURE : SEP 19 1996 <br />! <br />Title- 0� ��� n r/ SAN S�;r�: ;j,'`4 <br />Date: PI IRI 1r H H SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, 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 />Assigned to Employee # ()Lj 0 <br />Date Service Completed / / Further Action Required: Y / N <br />C .. <br />Service Code �✓ <br />Date � � / � ( <br />I <br />PROGRAM ELEMENT Z -3 0(c? <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />RENS <br />K—k/� A 9 <br />SUPV <br />•_/ / <br />ACCT � / ,::ao <br />UNIT CLK <br />_/ / <br />