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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # U c) Q RECORD ID # INVOICE # /J U <br /> FACILITY NAMEC��/ �LI I�T11•Irll` �? atv <br /> [:B <br /> LLING PARTY Y / N <br /> SITE ADDRESS -6-Q( IAA�E LJ 1 I � �M AYV <br /> CITY Luo i CA ZIP <br /> OWNER/OPERATOR BILL <br /> ING�7PARTY Y / N� <br /> DBA P � N /TMJ C1 ,' PHONE #1 (L0 )3- S3 <br /> ADDRESS S25 :r (R I/ NOZ-31— PHONE #2 (209 )53i-- <br /> CITY <br /> 209 )5 -CITY o STATE CPWF ZIP <br /> APN # Land Use Application # <br /> CSS_ (-70-2, LOS <br /> Dist Location Code <br /> .CONTRACTOR and/or t <br /> SERVICE REQUESTOR C�IVN���I1�J'Cr _ BILLING PARTY Y1 / N <br /> DBA S (� W`�I_`'� PHONE #1 (5to ) 9 33 - <br /> MAILING ADDRESS VC FAX # (w)933 - <br /> O S P <br /> � .� G <br /> CITY Ill �1� -�G-!� STATE ��1 ZIP <br /> 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 activity will be billed to the party identified as LING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prpa e#this application and that the work to be performed will be done in ®{!4}dap with all SAN <br /> JOAQUIN COUNTY Ordinance C es d Standards ate �nd F Caws. VV�� 11 ( i99�' <br /> SAN <br /> APPLICANT'S SIGNATURE V NCS �'� p B�CQAQUI"c.r�L'N <br /> ^� p� rvTai.f��.al:rH r sION <br /> Title: Aks <br /> ( Date: 10/--7 I1 <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: Service Code �Z <br /> Assigned to (�� L14: -Employee # 1 L -D3 Date IQ—/-42/ S <br /> Date Service Completed ` / _/ Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid '4nte of Payment Payment Type Receipt # Check # Recvd By <br /> `t I2g9 — to11-? 1g7 V11 C <br /> SUPV _/ / ACCT UNIT CLK <br /> R L1 s f-I' <br />