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0 SERVICE REQUEST 0 (EN 00 61) Revised 8/23/93 <br />EC <br />TY 10 RECORD 10 if INVOICE 0 D 5 O� <br />FACILITY NA14E 1*`AC-y TRuC V, ► BILLING PARTY Y J �N <br />SITE ADDRESS <br />55 1 W, L AacK R•D <br />CITY -ra A cy CA ZIP T <br />OWNER/OPERATOR CAA9-":5t-r BILLING PARTY 5 / N <br />DBA T2�G.V �`"' G'`' l`t'd ` PHONE 01 ( 51 C> ) 6S'�• (7 <br />ADDRESS ar= PA Pt -AAA- PHONE #2 ( Sita ) OW % -1 l C <br />CITY , 12�-11110 STATE GA' ZIP <br />APR 0 Land Use Application 0 <br />21 2 ` ?- — Og'IF <br />[BOS Dist Location Code <br />CONTRACTOR and/or <br />SERVICE REQUESTOR 1���� BILLING PARTY Y /0 <br />DBA W7,0% L-rc* EIU61tj&-&)�LjNJ 6r PHONE #1 ( ql(P )3"73- 11 GIB <br />MAILING ADDRESS PO exO)C i'0Z57 FAX fl ( 916 ) 373 - 11 -f2' <br />CITY W, SAC(�M&'1N'(10 STATE CA ZIP-fJr�OQ� <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 />cwt wcrc- t%&* 3co+ p-6• I. <br />I also certify that I have prepared this application and that the work to be performed will be done in acco a Ef"ll SAN <br />JOAQUIN COUNTY Ordinance CodespQ� Standards, State and Federal laws. I�F�,�Ai/E D <br />, <br />APPLICANT'S SIGNATURE <br />4� <br />Title: Qw , ! Date: 1Z ` `� QAN JOAQUIN COUNTY <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 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: �l�t�"l �r`' l�Z o7%(M VVU.(/1 Service Code �% s <br />Assigned to NJ Employee 0 Y Date 2 / y <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment Payment Type <br />Receipt N Check 0 <br />Recvd By <br />AD <br />521La 4 -0- . <br />-? <br />?J2 L2 [ <br />-2 <br />'315 <br />RENSP.5,/ C' SUPY _/J ACCT / UNIT CLK ____/ ! <br />11 <br />