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SERVICE REQUEST • {EH 00 61) Revised 8/23/93 <br /> =FACILITY # RECORD ID # /^p 1 TINVOICE # 1 /1��71.�; <br /> FACILITY NAME ��/ n,7 4/ ��`� `�' h' BILLING PARTY n / N <br /> SITE ADDRESS 1301 U' / b�— �� //�� <br /> CITY CA ZIP <br /> ` ® BILLIN / <br /> OWNER/OPERATOR G PARTY Y N`P/ <br /> DBA T"��//'� �1- G'�` t�� PHONE #1 ( �0 91 .J <br /> c�U / l� $ Yom[/G'G[F'.�'1�1 lvt � (��?/ <br /> ADDRESS PHONE #2 <br /> CITY �� STATE ��' ZIP Z(�1 <br /> 9 <br /> APN # Land Use Application # <br /> 1F BOS Dist Location Code <br /> CONTRACTOR and/or _ f _ <br /> SERVICE REQUESTOR ���M�S '�✓ ' '746-6 l�€�'� BILLING PARTY Y / <br /> DBAPHONE #1 O -_� <br /> MAILING ADDRESS -erX FAX # ( -) 43 <br /> 3 Z <br /> CITY STATE ZIP 52- <br /> BILLING <br /> 2-BILLING ACKNOWLEDGEMENT: I, 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 activi+:y will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> cdFti'y ►, <br /> I also certify that I have prepared this application and that the work to be performed will be done in as en haw mall SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, S ate and Federal 71s. `�ECEIVED <br /> APU 1CANT'S SIGNATURE <br /> DEC 1997 <br /> r <br /> COUNTY <br /> Title: ZAP Date: J 7 :2PLt01=I�GEA TIHSEERVI ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> AUTHORIZA ON 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: ��r2/ALt r,;.L Service Code � <br /> sc � s� <br /> Assigned to Employee # d (0 Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT J� <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> IV ?D1 <br /> REHS SUPV _/ / ACCT _/ / UNIT CLK _/_/ <br />