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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY 10 N RECORD ID it �I L INVOICE M <br /> FACILITY NAME QUL r- `JT�r _- BILLING PARTY Y / ON <br /> SITE ADDRESS lo-3,o S. "'DLIV AVE <br /> CITY 5To G�TO/V CA ZIP OS <br /> OWNER/OPERATOR QULK SZ'oP RA-P— ,S4 lAx, BILLING PARTY O / N <br /> DBA J� K-- S'� �P :+G PHONE #1 C S/o )—(,57- 85-0-t> <br /> ADDRESS 1JS76-7 S7 q PHONE 02 ( ) <br /> CITY STATE ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR IIU (TO/JCzi�LL�j��T f �N�i' BILLING PARTY Y / <br /> DBA tl l ( 1 t PHONE #1 37 - <br /> MAILING ADDRESS I i/��� I DZS FAX # (gf(p )3-73 - <br /> CITY W- 5ACi2/�MEY�rT�) STATE CA ZIP `TSAR <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. PAYMENTZ' W C wcrc r%&+ s-CA+ IP-6- <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 C Standards, State and Federal laws. J U L 3 0 1998 <br /> APPLICANT'S SIGNATOR <br /> PUBLIC HEALTH SERVICES <br /> Title: AkC" p�7 M� G��- Date: 2g �JLI� 9a ENVIROPaNiiENTALIiEALTH171VISIQia <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. icy <br /> Nature of Service Request: Service Code _ V <br /> Assigned to QN4 1 `t E� Date _�_/ 3 1D <br /> /� <br /> Date Service CcaQleted /� Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amaxrt Paid Date of Payment Payment Type Receipt 0 Check <br /> 0 Recvd By <br /> RENS / /Z "V _/_� ACCT _/ / UNIT CLK <br /> • <br />