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0 <br />SERVICE REQUEST <br />(EH 00 61) Revised 8/23/93 <br />FACILITY ID # 1 RECORD ID # 1 _� C� INVOICE #- L) <br />U <br />FACILITY NAME _ . K'T�l.� ru i d G.iIJ BILLING PARTY Y' / N <br />SITE ADDRESS L-4' <br />CITY �" (>/� CA ZIP !Jz _®b r31 I <br />OWNER/OPERATOR <br />BILLING PARTY Y / a_j <br />DBA f�Y2'�� v PHONE #1 ( ) ' <br />ADDRESS % �� C� l I PHONE #2 ( _)J -�-- 3 S <br />CITY i'�;�'�2�/// �J STATE _ ZIP C 2b,— � 10� <br />FAPN # �Larxl Use Application # <br />BOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR � BILLING PARTY 0Y / N <br />DBA <br />MAILING ADDRESS <br />PHONE #1 (-qLL_)q 3 - q (1( _ <br />FAX # (� ) - 61IG 7 <br />CITY 61 ,arl �I J'< STATE _ ZIP "lJ <br />.-.....e-mv <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that At Cylanddp project specific <br />PNS/EHD hourly charges associated with this facility or activity will be billed to the party identifie as BILLING PARTY on <br />Page 1 of this form. JUL 111997 <br />1 also certify that I have prepared this application and that the work to be performed will be doneQ ac ordance with all SAN <br />SAN JNTY <br />JOAQUIN COUNTY Ordinance Codes and S ndards, State and federal laws. PUBLIC HEALTH SERVICES / 'V/ ENVIRONMENTAL HEALTH DIVISION <br />APPLICANT'S SIGNATURE <br />Title <br />Date: /o -7- <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 avai LaDle ana aC lne same I 1W i i o In— I •- �• •••i -r <br />Nature of Service Request:ot-� I Service Code <br />Assigned to LAi Employee # 341 ?�— Date <br />Date Service Completed / _/ Further Action Required: Y / N I PROGRAM ELEMENT 2 Z C> <br />Cy <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />RENS / / SUPV _/ / ACCT {)/�/ EU►T CLK���� <br />