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9 SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br />FACILITY ID # <br />c 4t9- p`/J z rr <br />RECORD ID # <br />t <br />INVOICE # <br />Recvd By <br />Fee Amount <br />Amount Paid <br />h% <br />DBA <br />7aAC-y '" CV4" *t la -`J70 <br />PHONE 01 ( JrI <br />FACILITY NAME 1A C - <br />SITE ADDRESS <br />st-0 P BILLING PARTY Y I ` J <br />CITY T L� CA zip 3 -t _ <br />OWNER/OPERATOR <br />c 4t9- p`/J z rr <br />Date of Payment Payment Type <br />BILLING PARTY <br />Check # <br />Recvd By <br />Fee Amount <br />Amount Paid <br />h% <br />DBA <br />7aAC-y '" CV4" *t la -`J70 <br />PHONE 01 ( JrI <br />) 45 <br />ADDRESS <br />T"" 3-ACpk-It 0:�-rvvlk OOZ <br />PHONE #2 (SiC3 <br />CITY 1 � `o� STATE C� <br />FAPZN # Lend Use Application #I <br />a ,fir <br />ZIP f +S51 _ <br />BOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR <br />1`��� K� �—� <br />BILLING PARTY <br />Y /Q <br />DBA <br />W>aL- -"V G)V6,(tJ &V -J J6r I� <br />PHONE #1 ( ql % <br />)3-73 _ 11 G a <br />MAILING ADDRESS <br />PO vdx t�D*Z157 <br />FAX # ( 11(0 <br />) 3%5 _ ti 72 <br />CITY W, S4Ch'GR.4ME STATE CA' ZIP <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 />U.) G wCr<_ no -t ScNt <br />1 also certify that I have prepared this application and that the work to be performed will be done in accordPnoe s+) h;:4!AJ SAN <br />JOAQUIN COUNTY Ordinance Codes 4r.4 standards, State and Federal Laws.g Rzr, <br />APPLICANT'S SIGNATURE <br />Qw (� Date: ' 1 ZV1,�SA <br />N �C)AOUIN COUNTY <br />Title: PUBLIC HEALTH SE9VICES <br />�NViRONMENTAL HEALTH DIVISION <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. <br />Nature of Service Request-,-(- <br />equest/ ( -'1 Service Code V 5 <br />�! 1 SS (J �'J Employee # �-1 / <br />Assigned to Date /y� <br />Date Service Completed / / Further Action Required: Y / N [PROGRAM ELEMENT <br />SUPV /_f ACCT _/ / <br />Date of Payment Payment Type <br />Receipt 0 <br />Check # <br />Recvd By <br />Fee Amount <br />Amount Paid <br />h% <br />1-3 u52-1 <br />�� <br />�� <br />SUPV /_f ACCT _/ / <br />UNIT CLK <br />RENS j / i'� <br />j <br />i <br />