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(EH 00 61) Revised 8/23/93 FACILITY NAME (7)&�>EBILLING PARTY I C:)/ Ej SITE ADDRESS _ 1\51 1J ,&P!yF-- / CITY IM ah) X14" CA ZIP P�s'33L- 042-1 , BILLING PARTY Y / PHONE #1 (_ ) ' - 40;k STATE CAr- ZIP �53362 Land Use Application # BOS Dist Location Code CONTRACTOR and/or SERVICE REOUESTOR �� If DBA —44slra- MAILING ADDRESS aS �S 60r, tit./ , N, � -f-d'-�Ur BILLING PARTY -0IM / �j PHONE #1 ( ) D� )'VG I - G S S 2 BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. y� 1 also certify that i have prepared this application and that the work to be performed will be done in a�Q+��+ith all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. Title & Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator bNtiI 4U agft the property located at the above site address hereby authorize the release of any and all results, geotechnlc/ environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DTVI it is available and at the some time it is provided to me or my representative. Fee Amount F��RCORD ID # Payment Type INVOICE # �/3 L/I FACILITY ID # q - a--5 q 141 1 -719 � - V-11 FACILITY NAME (7)&�>EBILLING PARTY I C:)/ Ej SITE ADDRESS _ 1\51 1J ,&P!yF-- / CITY IM ah) X14" CA ZIP P�s'33L- 042-1 , BILLING PARTY Y / PHONE #1 (_ ) ' - 40;k STATE CAr- ZIP �53362 Land Use Application # BOS Dist Location Code CONTRACTOR and/or SERVICE REOUESTOR �� If DBA —44slra- MAILING ADDRESS aS �S 60r, tit./ , N, � -f-d'-�Ur BILLING PARTY -0IM / �j PHONE #1 ( ) D� )'VG I - G S S 2 BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of some, acknowledge that all site and/or project specific PNS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on Page 1 of this form. y� 1 also certify that i have prepared this application and that the work to be performed will be done in a�Q+��+ith all SAN JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. Title & Date: AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator bNtiI 4U agft the property located at the above site address hereby authorize the release of any and all results, geotechnlc/ environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DTVI it is available and at the some time it is provided to me or my representative. Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By q - a--5 q 141 1 -719 � - V-11 ')-° q-C' [REH�S�L�ZACCT 7 //� UNIT CLK _/ /