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• . SERVICE REQUEST /& (EH 00 61) Revised 8/23/93 <br />- :) � q (=, � L I <br />FACILITY ID # I I RECORD 1D # INVOICE # Fyqqr� <br />i; <br />FACILITY NAME O n e S To /D m 0._ �- k e _ BILLING PARTY Y / �N <br />SITE ADDRESS INe S T f^ o I `j <br />CITY M C, -n -f -e C 0 CA ZIP q 5'-3 3 (Q <br />/6P�R F9R DVl r C o(, 0. V- G1 O Z� 01—BILLING PARTY Y / <br />DBA I I lI PHONE #1 (20q <br />ADDRESS I - y . �� O X % 2 V -FAX <br />ANBNE #2 <br />APN # <br />CITY M Gt -YA (-- C Q-- STATE CA ZIP -I 3 3 4� <br />IFLand Use Application # <br />BOS Dist Location Code <br />NTRACTOR and/or _ �' <br />RVI CE REQUESTOR ! �i 2X7 t�r TY' `y1 A G /a y- S �YLC <br />DBA T-1 <br />ADDRESS <br />BILLING PARTY 0 / N <br />PHONE #1 (.&OZ) ) *G LI - <br />FAX <br />FAX # (;Lo Z) 4-(,l - �n 31 ;�- <br />CITY ✓C ( -c, C /<• TO 'y— STA1E C-,� ZIP ?-5"- 05 <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 />I also certify that I have prepared this application and that the work to be performed will be done in acc0?1%" p1Jll SAN <br />JOAQUIN COUNTY Ordinance Codes andhStandard,s, State and Federal laws.+%k <br />LICANTIS SIGNATURE : <br />le: rV1 o 12 C / �� Date: Jr / D SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DIV SfQN <br />NOR17ATION 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: ) I Service Code <br />Assigned to ` mployee # Date <br />Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />RENS SUPV _/ ACCT UNIT CLK/_/ <br />