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SERVICE RE ST } (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # Cf , ? INVOICE # <br /> FACILITY NAME ��4 ® [/O C/,,g»Q �y� BILLING PART _ Y / p <br /> SITE ADDRESS 8S 0 <br /> CITY CA ZIP <br /> WER/OPERATOR �)A BILLING PARTY Y / <br /> DBA' PHONE #1 ( D )36 - .3 7,a.5— <br /> ADDRESS ,CLrrce 0.4 PHONE #2 C_)-- <br /> 's <br /> � i CITY STATE ZIP T <br /> —APN #¢ Land Use Appl i cation # ' <br /> BOS Dist Location Code <br /> JTRACT�end/'or �.[es/���-_ •�-- r <br /> NICE'.REQUESTOR C�-=Ij' '4'"° :C�t�1" " 'i' BILLING PARTY <br /> s-. <br /> PHONE #1 (.z® <br /> (LING ADDRESS , .�'(,(}`� v�' FAX # ( ) <br /> .CITY ` - STATE ZIP 7.�i1.17✓.G <br /> :LLING ACKNOWLEDGEMENT:; t, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> IS/EHD hourly'charges associated with this facility or activity witl be billed to the party identified as the BILLING PARTY on ` <br /> age 1 'of this <br /> form.:—r <br /> PAYMENT <br /> also-certify that I have prepared this application and that:the work to be performed wilt be done in acco l!t)SAN <br /> )AQUI N COUNTY„Ordi nance Codes and Standards, State and Federiil laws. • <br /> ro?- T`.. „ ' 201998 <br /> IV <br /> 'PLICANTOS SIGNATURE <br /> �1 - <br /> SAN JOAQUIN COUNTY <br /> tle .iLLL Date: PUBLIC HEALTH SERVICES w <br /> 'PICPMNMENTAL HEALTH DIVISION <br /> JTHORIZATION TO RELEASE INFORMATION: In^addition to the above, when applicable, 1, the owner, operator or agent of samei %of <br /> ie property located at the above site address herebyauthorize the release of any and all results, geotechnicat data and/or- <br /> ivirormentat/site assessment infotmmtion to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as. <br /> `":is—available and at the same time it is provided to we or my representative. <br /> Nature of Service Request: Service Code <br /> Assigned to mployee # Date <br /> Date-Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT G.. <br /> Fee:AmountF Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> Z"® StIPY r ,_� . / ACCT a3/ SIR UNIT CLK <br /> HS C <br />