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ILITY NAME C� <br />--------- (9So mccol-t <br />SERVICE REQUEST _ (EN 00 61) Revised 8/23/93 <br />ZIP JAZ 1� <br />mirR/OPERATOR C��! FtEQ � C1--07-:" O� C L, I BILLING TARTY '/ N <br />PIIONE N1 ( ZI 3 )_ 7"/74 118 <br />DBA ^` <br />2601 �}-S ZAj �1 `TC. _ PIIONE 02 t ) <br />ADDRESS Q Q <br />STATE C' r ZIP <br />CITY o irl rn - ---7 <br />CONTRACTOR nrxf/or �eE� <br />oea —w, <br />toy <br />SERVICE REOUESIOR Y/` <br />vAJ (—MV F+fC� <br />Ir7/C Zcv"e0t4 }(_ PHONE xl <br />-� / Qn <br />NC ADDRESS / % rAA <br />MAILI �U Q <br />CITY <br />STATE C� ZIP X806 <br />IJOAO <br />LING ACKNOWLEDGEMENT: 1, the underslgnedTco—er,yorrator r agent of will be billed tontheeportydge hidentifiedat all eos�therBILLINGtPARYYIonc <br />/EHD hourly charges associated with tills <br />e 1 of this form. ' <br />all SAN <br />lso certify thnt I have prepared this npplication nixf that the work to be performed will be done in occor r�aya NT <br />t E D <br />UIN COUNTYOrdinance Codes and Stn�ds, State and rederel laws. °W' <br />C% <br />X0,2 C��nT-r�D 6t2oCF2-5 <br />APPLICANT'S SIGNATURE <br />V P�/ �DS �«T Date, 8 lS g� zr ,oAc'UIN u <br />T I t l e: %p .i' 11i ze L'TH'SFR'JI ES <br />FN I- Viv <br />AUIIIOR17ATION i0 RELEASE INTORMATION: In addition to the above, when nppllcnble, I, the owner, operator of i I Ha 1. W191�7N <br />the property located at the above site address hereby nuthorite the elease ofnny SERVICEd nit <br />ENVresults, <br />LgeoteTNnicalDIVIdotION a/oon Or <br />as <br />envirormiental/site assessment informntlon to SAN JOAQUIN COUNTY PUBLIC <br />it is available and at the same time it Is provided to me or my representative. <br />Service Code <br />Nature of Service Recf/est: <br />k Employee N' DDD Dote <br />AssigiMd to <br />Date Service Completed / / further Action Required: 6 / N <br />PROGRAM ELEMENT <br />fee Atitount Amount Paid <br />91- <br />e � <br />H <br />I <br />Date of PoyinReceipt A Check N Recvd Byent I Payment Type J <br />_ T <br />w� -t <br />6•: i - UNIfCLK <br />