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r <br />��rPrlt SRDo �-! g <br />rACILITY ID # <br />_ \ ! -7 I SERVICE R <br />RECORD IDN 1 <br />V V_( (SERVREO) Revised 8/23/93 <br />INVOICE # <br />rACII.ITY NAME /V► �V l liC �1 l v / 1 BILLING PARTY Y / y <br />SITE ADDRESS <br />CITY �" ( CA ZIP r) <br />OWNFR/OPERATOR <br />{�j�/� )� <br />I �y Y l�i(iL Y L //i <br />BILLING PARTY <br />DBA <br />be billed to the party '41(0 PARTY on <br />rnge 1 of this <br />PHONE #1 (� 0 )7 ?- LO I <br />ADDRESS <br />-07 <br />qD <br />` L D ` ` l #2 <br />Payment Type <br />l/V <br />1/U� • 1 <br />PHONE <br />that I have <br />prepared a lication and that the work <br />to be performed will be ds e c With all SAN <br />" '✓�'�{ <br />CITY <br />l�I l�V <br />STATE <br />ZIP 1 L <br />APN# <br />and Use Alication # <br />is L( <br />���� <br />IFpp <br />BOS Dist Location Code <br />CONTRACTOR and/or <br />1 <br />� <br />'j� <br />&(VIU <br />ILC(-)- <br />SFRVICF RFOIIFSTOR <br />nfffl `t <br />( <br />BILLING PARTY <br />Y / N <br />ORA <br />PHONE #1 ( `✓I�) <br />MAILING ADDRESS <br />�/ .�I <br />.1 ✓L/� <br />�}✓�- /Oe)16 <br />FAX # (r `��- I/�✓ <br />CITY <br />� �, <br />l/y /� <br />STATE (�k <br />ZIP j q��" 1 LP <br />RILLING ACKNOWLEDGEMENT: <br />I, the undersigned owner, operator or agent <br />of same, acknowledge thd� ject specific <br />PHS/END hourly <br />charges associated with this facility or activity will <br />be billed to the party '41(0 PARTY on <br />rnge 1 of this <br />form. <br />Fee Amount <br />Date of Payment <br />Payment Type <br />Receipt # ` <br />t <br />in 1 rdui <br />I nlso certify <br />that I have <br />prepared a lication and that the work <br />to be performed will be ds e c With all SAN <br />JOAQUIN COUNTY <br />Ordinance Codes St rds, a Fede at <br />ENVIRONMENTALPeALTH <br />APPLICANT'S SIGNATURE <br />f <br />/%N /h' U� <br />PERMIT/:"' -�)ViCES <br />Title: <br />Date: <br />u � i <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 ENVIRONME%TAL HEALTH DIVISION as soon as <br />It is available and at the same time it is provided to me or my representative. <br />Nnture of Service Request! <br />v <br />Assigned to C , (Ak Employee # <br />T <br />Date Service Completed -/-/ Further Action Required: Y / <br />Service Code <br />Date cl--/1 75 / <br />PROGRAM ELEMENT Z 7j 1 VID <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # ` <br />Check # <br />Recvd By <br />�! <br />a <br />-F77i7 <br />is L( <br />���� <br />