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SERVICE REQUEST CEN 00 61? Revised 8/23/43 <br /> tip 0 : RECORD YD # 1 (�(" INVOICE # <br /> BILLING PARTY -Y <br /> ADDRESSI SPO 1 fi1G� ►C.C� <br /> 't. TY- -(-. CA ZIP <br /> /OPERATOR'.- <br /> i(/ 1� BILLING PARTY Y / <br /> rt�hDBAPHONE #1 (1)ala -3 <br /> :ADDRESS' 6.0 41IM4 PHONE 02 <br /> -;4" CITY.. STATE ZIP <br /> APNI# Land Use Application # <br /> r^ •-_ SOS Dist Location Code <br /> CONTRACTOR•'and/ora . <br /> SERVICE RECUESTOR IV C'OeA.c-'`� ��'""� �""' BILLING PARTY �/ N <br /> r ? PHONE #1 (.Z.6 9 ) 4/6 /- 3 3'7 <br /> f �rV =' . <br /> 4AILING-ADDRESS/ FAX # (202 <br /> CITY � ��� STATE ZYP p:9:! <br /> +BILLING ACKNOWLEDGEMENT: •'I, the undersigned owner,•operstor or agent of same, acknowledge that atL site and/or project specific ''•• <br /> PN§/EHD hourly charges associated with this facility or activity wilt be bitted to the party identified as the BILLING PARTY on <br /> Pageil of this form. PAYMENT <br /> /► MEN <br /> `also cartify_that,'l have prepared this application and that.the work to be performed will be done in arca ltlfVE3t)SAN <br /> 0AQUIN COUNTY,,Ordinance Codes and St rds, State and Fedensl Laws. <br /> rtt�, ,,v•rs: s :$ , £:.. 2 01998 <br /> iPPCICANT+SYSIGNATURE <br /> � .;. <br /> `� - •:- _ -• _ - SAN JOAUUIN COUNTY <br /> S7 <br /> Date: / PUBLIC HEALTH SERVICES <br /> ).„tie'•,e• / tONMENTAL HEALTH DIVISION . <br /> AlJTHORYZATION'TO RELEASE INFORMATION: In addition to the above, when applicable, Y, the owner, operator or agent of same, of <br /> -,ihi property located at the above site address hereby authorize the release of any and aLL results, geotechnicat data and/or <br /> =emirormental/site assessment'information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as. <br /> Xi1;`rig available-and at the same time it is provided to me or my representative. <br /> ,K <br /> 4iature`af Service Request: Service Code <br /> 1�t ®. Date <br /> 7(�Agscsigned to' mployeo # ( � � f <br /> te•Servica., Leted I / Further Action Required: Y / N PROGRAM ELEMENT Z o <br /> ?ej-Date of Pa <br /> Fee Amocrrt <br /> `A Paid Paid 3�'� , yment:•.• Payment Type •: Receipt # .. Check # Recvd By <br /> m .2. _t S�, SUPV' "I,? ,�, /- / ACCT �/ / UNYT CLK ®�®J " <br />