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* SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # FFECORD ID # INVOICE # <br /> FACILITY NAME /u�mwtv- 6� FBILLING PARTY Y / N <br /> SITE ADDRESS _( A� <br /> TCITY LODI CA ZIP-9S69 J <br /> •1 <br /> OWNER/OPERATOR BILLING PARTY ©©^^��Y / <br /> DBAf _ PHONE #1 (�_) SP✓- 'S M <br /> ADDRESS L� V�!�3) �ILI/.r PHONE #2209 )583 - <br /> CITY STATE ZIP C�32 30 <br /> A <br /> P # Land Use Application # <br /> Dist FL <br /> ocation Code <br /> X70- BOS 2 <br /> CONTRACTOR and/or �j1�D1 <br /> SERVICE REQUESTOR =BILLING��}-��'J PARTY Y / N <br /> DBA 44, - C-/'dCt�IVC IC,11yfA PHONE #1 (5JO) 133 - 0578_ <br /> MAILING ADDRESS AS W - #Im FAX # (SIO _) 33 - <br /> CITY �h� an`- STATE L ZIP 94s-c . <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 the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have pr pa rPd <br /> this application a t t the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance C n ar ,- to d deral laws. <br /> a <br /> APPLICANT'S SIGNATURE N Ct: PAQ&Lh i L <br /> TitleMdf��TjA 6�&bx*Date: 97 S !�1 <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, theRAMfWfor or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and ap &11ii'fgb'btechnical 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. OCT 1 7 1997 <br /> Nature of Service Request: SANJ AcS+�tt4�i11(IliYie 03.(L <br /> 7 PUB <br /> LIC <br /> ENVIRONYviE <br /> Assigned to + rrployee # _ Date t D <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> ­7 5A IS 3 <br /> i <br /> E <br /> C 1o.-/ SUPV _/ / ACCT / / �� UNIT CLK _/ <br />