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• SERVICE REQUEST • (EN 00 61) Revised 8/23/93 <br /> FACILITY 10 # RECORD 10 0 v ' 3 INVOICE M <br /> -1 <br /> FACILITY NAME QV�� ST�r l G BILLING PARTY Y / ON <br /> SITE ADDRESS �' ouvc- "'WE- <br /> CITY <br /> VECITY 5To GkTo/�I CA ZIP �J 20S <br /> OWNER/OPERATOR QuL� SToP ItiIZSr • _ BILLING PARTY YO / N <br /> DBA �J� ��- S4'DP Ifo PHONE #1 <br /> ADDRESS ��7E1Q1 �isE S7 PHONE #2 <br /> CITY �N-'"`d� STATE GA" ZIP 14-E 33 <br /> APM # — FLand Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR ��J�YlTO� Cs1n� 1Q1IJCs f SNL BILLING PARTY Y / �N <br /> DBA PHONE 01 3'7 - 1161�> <br /> MAILING ADDRESS r 0 oci) FAX # ('71(- ):3-73 - ��1 2- <br /> CITY W- GR�MC� STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> WC wcr<, ma-t SrNt ��'• �• <br /> I also certify that I have prepared this application and that the work to be performed will be done i+�W?A"aith all SAN <br /> JOAQUIN COUNTY Ordinance C Standards, State and ederal laws. " , <br /> IQ n C1qA <br /> APPLICANT'S SIGNATUR <br /> Title: Date: 2g �JLy AIN jQ QUINcu+)N Y <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <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 SAW 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: A Service Code _ <br /> Assigned to s 101 ni�Q 1I�P�-�' EsPloyee 11 IG,U.1—�= Date <br /> Date Service Completed /_1 Further Action Required: Y / N PROGRAM ELEMENT M �' -_ <br /> Fee Amotslt ARrount Paid Date of Payment Payment Type Receipt 0 Check E Recvd By <br /> (� <br /> RENS �/3 $UPV _J_J ACCT _/�f UNIT CLK <br /> 0 <br />