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SERVICE REQUEST Conk 1n5#2110n� (EH 00 61? Revised 8/23/93 <br />FACILITY ID # I 1 RECORD ID #1 0 l 5/ 78 1 INVOICE # <br />FACILITY NAME /oLland %�2leyen �fj{�P'%OV�SZ BILLING PARTY 1Y- / N <br />SITE ADDRESS 46,27 12cl Vtv)c, Drive- <br />CITY <br />rn%e <br />CITY 5to kion CA zIP 015W7 <br />ERATOR jpvthia,�i L,CJf �ofation BILLING PARTY (-J / N <br />DBA (7–eleven aJICXe, * ZO(-3Z) PHONE #1 (� 14� ) �a�- Z <br />ADDRESS Z �J3�i %00 M CPA0 i Way J � 10j PHONE #2 ( Ilv , G31 - 7711 <br />APN # <br />CITY &700 "wCC STATE GA zIPIF <br />�(Ow <br />Land Use Application # — <br />BOS Dist Location Code <br />NTRACTOR and/or <br />U <br />RVICE REQUESTOR IZ14L I SIOIh L�O�ia l - T� vhJ✓l� BILLING PARTY Y / N <br />DBAf nt for 5aAl a PHONE #1 (GI��O ) 4003 <br />ILING ADDRESS &50 HDuj . Ayelye, / /✓ FAX # ( �«/ ) (/'C�O - 4&71 <br />CITY _ lCYiram�Y1�G? STATE /-,A zip 5&zc7- <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that at[ site and/or project specific <br />PHS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />Paae 1 of this form. <br />also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws.' <br />APPLICANT'S SIGNATURE <br />Title:�Vlt IJLJY•►�r�Gi a�TOV1 Date: <br />H Slt1VjCE'€� <br />HEALTH D#VI loo <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: � _�_ � � � b .cam I Service Code 0 3 ) _ <br />Assigned to WDEmployee # Date `7r" / Z / 1, <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br />F <br />REHS - <br />/z�-I SUPV I W/—/— <br />I ACCT I —/—/ –0- <br />//_0. I UNIT LK I �/ / <br />MR <br />L <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />� <br />t 5(.,e- r <br />gI'm Iq g <br />✓ <br />w 5a <br />"6 <br />F <br />REHS - <br />/z�-I SUPV I W/—/— <br />I ACCT I —/—/ –0- <br />//_0. I UNIT LK I �/ / <br />MR <br />L <br />