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6 SERVICE REQUEST I 1 (EH 00 61) Revised 8/23/93 <br />FACILITY ID # RECORD ID # I'WVOICE <br />FACILITY NAME F1,AM5- C fouo(2,S 1AII-Y, BILLING PARTY Y / <br />SITE ADDRESS ��3dI w. K677C-S A -t,) <br />CITY 0001 <br />CA ZIP 6157 <br />OWNER/OPERATORnN <br />Payment Type Receipt # <br />Check # <br />BILLING PARTY <br />/ N <br />DBA <br />FLAIv? � ci&uof`- (�iL <br />PHONE 01 <br />(2-"o9 ) 332- 3433 <br />ADDRESS <br />t 3 o I W F c` 7( YVI( <br />PHONE #2 <br />( <br />) <br />CITY <br />1a 01 STATE GR <br />ZIP DS -Z'4 2— <br />APN # <br />Land Use Application # <br />(93(— C -24o <br />, 55 <br />Dist <br />LOS <br />Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR <br />P-164- Vim(--rb1J F Ml Ie LEE <br />BILLING PARTY <br />Y � <br />DBA <br />( J/�% 6N(,qnJ&-EgJ 6,.4 l Al C. _ <br />PHONE #1 <br />( gf (-- <br />) - ! l 68 <br />MAILING ADDRESS <br />1b7FAX <br />PaC60-/1075-# <br />p <br />( !�6 <br />T✓ <br />_) - �l�7- <br />CITY W. ✓A'f- '^M�D STATE <br />cy <br />ZIP C I <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that at[ 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 />Z' we wcrc no -F s<H+ <br />r <br />I 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 C9d" St ndards, State and Federal laws. <br />APPLICANT'S SIGNATURE <br />M <br />Title: �m""N' ��T�// (� (it/)4[✓Za/�! v/v�vDate: <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: VL .�J'Y�/t Service Code (2-31 <br />Assigned to Employee * Date <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT_ <br />Fee Amount Amount Paid Date of Payment <br />Payment Type Receipt # <br />Check # <br />Recvd By <br />RENS I J I SUPV I _/_� I ACCT I I A O) / l9' / I UNIT CLK I <br />