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SERVICE�Y••,.,.,. „•' REQUEST (EH 00 61) Revised 8/23/93 <br /> #• <br /> - �• ° ' ,,, RECORD 1D:# INVOICE # <br /> •1bA a <br /> I p NAM QAA BILLING PARTY Y / <br />' QODRESS �S" <br /> CITY CA ZIP 7SaZ`7L0 <br /> BILLING PARTY Y / <br /> .R®AERATOR ' <br /> DBAPHONE #1 (�D�) 3�on - 37$-5— <br /> ADDRESS &10 PHONE #2 <br /> f` CITY ' STATE ZIP <br /> ' PN # Land Use Application # <br /> LBOS Dist Location Code <br /> A <br /> TRACTOR end/or —�— <br /> 5ERV ICE REGUESTOR �� I V ��°��*'; BILLING PARTY �/ N <br /> { DBA. '1 `® 1 C 11 PHONE #1 <br /> IIiAILING <br /> ADDRESS, a FAX # (.209 ) 416 <br /> s " ;CITY" � STATE A ZIP <br /> 4 <br /> 'BILLING ACKNOWLEDGEMENT: 1, the undersigned owner; operator or agent of same, acknowledge that all site and/or project specific <br /> $PNS/EHD hourty'charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> age.tl of.*,this form r r <br /> PAY MENT ; <br /> aiso•certify*that t have"prepared this application and that,the work to be performed will be done in acco JIUEI)SAN <br /> gAQUIN COUNTY,SOrdihence Codes and Standards,:.Sxate and Federtil laws. <br /> ;. x. . 2 01999 <br /> LICANT°S SIGNATURE d' <br /> r .(e °'' SAN JOAOUIN COUNTY <br /> PUBLIC HEALTH <br /> tle �✓tL list Date: el"MNMENTALHEALTHICES DIVISION <br /> UTHORIZATION'TO RELEASE INFORMATION.' In addition to the above, when applicable, I, the owner, operator or agent of same, of <br /> "p. <br /> tie'property tocated at the:above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> anvir tat/site assessmentAnformation to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> 1ifita available and at the same time it is provided to me or my representative. <br /> 46ture of Service.Request: Service Code <br /> e st, e <br /> ssi Yto' � mptoye® # Date <br /> ,Ofsts Service Camptated ,F 1 / > Further Action Required: Y / N "' PROGRAM ELEMENT <br /> ee4' t" t Paid 7.4-1 YI.0atw of Payment ^ Payment Type Receipt # Check # Recvd By <br /> ACCT ' /--/ UNIT CLK <br />