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1 <br /> SERVICE REQUEST "!� s,r-,•,.a (SERVREQ) Re sed 8/23/93 <br /> FACILITY ID # RECORD ID # <br /> g' INVOICE '# ` <br /> FACILITY NAME n Y1 S CW Y� Y Y Y / <br /> SITE ADDRESS 1 ere -K- i C C-\O-A p (2ck . <br /> CITY YY)(�Nrtu,:2� CA ZIP `0533(.0 <br /> OWNER/OPERATORy�Y IV1\Cl W ti w �© / VV WlSi1)N BILLING PARTY ( Y) / N <br /> DBA PHONE #1 ( ) �- <br /> ADDRESS K 1 C Y C I C-0,MP (Z41 PHONE #2 <br /> CITY r1 tcC-C,- STATE Ck ZIP qC:)'3 <br /> APN Lase Application aF <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR I `��L 1 • AY),i�Cn BILLING PARTY Y / 0 <br /> DBA I VQ 1 0 • t'1 Y\(,�LVSGY-N `t 50<- JY-N� PHONE #1 <br /> MAILING ADDRESS ZZ P-� ' `� tVLLa vv--, FAX # 333 - 93c3 <br /> CITY Lo\� STATE Cl ZIP CAS Z40 <br /> BILLING ACKNONLEDGEMPNT: 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 /> PAYMENT <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in acc&tftCreff+#r;'F�l SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, Stat and Federal laws. <br /> r <br /> J U L 17199 <br /> APPLICANT'S SIGNATURE <br /> JOAQUIN COUNTY' <br /> G} / PUBLIC HEALTH SERVICES <br /> Title: C(Gs�4� l9`� C9ttJ1^e� _ Date: �4, <br /> E"FM7ENTAL HtHL H 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: t�o< St"-r-e,: I f'y S t" Service Code <br /> { <br /> Assigned to ( a Employee # (J Z�6L: _ Date — CLI <br /> Date Service Completed �/ f / Further Action Required: Y / a [PROGRAM ELEMENT :Z <br /> P <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> E <br /> S _/ / SUPV C_ / ACCT _/ / UNIT CLK _/ / <br />