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SERVICE REQUEST <br />(Ell 00 61) Revised 8/23/93 <br />FACILITY ID #F O RECORD ID # JLI-�J J INVOICE # D 14 j �� g <br />FACILITY NAME FI -A C-- UC) BILLING PARTY Y- / <br />SITE ADDRESS O k�T LEMS L/v <br />CITY (,C>19 I <br />OWNER/OPERATOR <br />DBA <br />I�L�7E CS2�FF IRNA <br />F&AN6 CMU62 ) (N <�-- . <br />CA Z I P <br />BILLING PARTY / N <br />PHONE #1 ( 2v4 > -33`x- 3233 <br />ADDRESS 30 I LN, kE77C6MAi) &'IV �jPHONE #2 <br />CITY <br />L00STATE ( 4 ZIP 1t 2' <br />APN # �Larxl Use Application # <br />Q 2 I l b ¢0 BOS Dist I::�Ltion Code <br />CONTRACTOR and/or �j <br />SERVICE REQUESTOR � K E LEE 1Z(Ck'4�zo �LZ�� BILLING PARTY Y / ON <br />DBA W4L7Dl ���� � //1S �NC PHONE #1 () 373 - (((,8 <br />MAILING ADDRESS PC) r✓v-,e- aZS FAX # ( 37-4 - rl 7Z <br />CITY V&757 :5AC4gM STATE ZIP g'z' q I. <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific <br />PIIS/END 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 p ared this <br />'' application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance C es and SFanaards, State and Federal laws. <br />f�' �� <br />APPLICANT'S SIGNATURE <br />TitIP! Gif• J2,�Cp-r 0 (AU -OA) O 6'& Date: <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: <br />Assigned to ��c�L•4 �►V r� Employee # L <br />Date Service Completed / / _ Further Action Required: Y / N <br />Service Code <br />Date <br />PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />RENS/�/ <br />SUPV _/ / ----T-=Lp <br />J <br />RENS/�/ <br />SUPV _/ / ----T-=Lp <br />J <br />