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SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # 0 RECORD ID # 10 F INVOICE # b3 a 5-ZP <br /> / N <br /> FACILITY NAME 0- P-- BILLING PARTY Y <br /> �J I U ✓1 C� �--� <br /> SITE ADDRESS 6 E7-11I-lVa"If �b0 �C2&cI <br /> CITY ISS oc CA ZIP /Sa/5 <br /> OWNER/OPERATOR Ss I�') C�2��//l d0 [EIN�GPARTY 0 / :N�] <br /> DBA d/Z/�/� O PHONE #1 (,20�' <br /> ADDRESS S6 (ice C//G /(7 l/`--O Cl G� PHONE #2 ( ) <br /> CITY S �/C/� -7Z0 STATE Clq ZIP 9sa�5� <br /> APN 0 IFLand Use Application # <br /> FBOS Dist Location Code <br /> CONTRACTOR and/or / n m <br /> SERVICE REQUESTOR /rI/�G e- 2r�C/. <�/. /O/�� BILLING PARTY Y / N� <br /> DBA A/012 4=- Z/2(f PHONE #1 <br /> MAILING ADDRESS B /`J S/C �� FAX # ( )2-2a- <br /> CITY <br /> 333-CITY /�CJlS7 �SiD� /�/� /Y1 T1��D STATE Com'_ zip 9S U �7/ <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. — 131* 11 ' rl fartl S 1^nW f�Cccl G��oOu J OW ✓ cvz/ oPc l`c,+o� <br /> wt wcrc no-i- scHt P't• I. <br /> r <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 /> JCAQUIN COUNTY Ordinance Cod and to ards, State and Federal laws. <br /> r i iA A t" <br /> APPLICANT'S SIGNATURE �t 1 <br /> Title: r6 �, QG OCT'- 41996 <br /> 6"�UAOWN��p �j Date: <br /> �p <br /> COauNr�' <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, t�h��4r4�IGOEator or-a�eigtc of same, of <br /> vl ((tiRl1 <br /> the property located at the above site address hereby authorize the release of any and all r'e�u� �''-geotephr�ia1 to and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISI 014 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 C) <br /> Assigned to l 44W Employee 0 N �� � Date {� �/��_ <br /> 97 (1 <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 /> _. 0170 . � io�4lc1(a f►ap�� <br /> REHS /� _ SUPV —/__/ ACCT <br />