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SERVICE REQUEST (Ell 00 61) Revised 8/23/93 <br />I <br />'a 9 RECORD ID # /y, I INVOICE # I �yio57 <br />FACILITY ID # I j `J �� �jl <br />FACILITY NAME - BILLING PARTY Y / N <br />SITE ADDRESS f 'ccoI— <br />CITY J�y CA ZIP <br />r <br />R/OPFRATOR _ C��r/ �e� �� C A KILLING PARTY Y / N <br />PIIONE #i �Z 7y 76 �8 <br />DKA <br />ADDRESS <br />Z'C-"O / A\\ <br />PRONE #2 ( ) _ <br />CITY <br />/ni1'iSTATE ZIP <br />—_ - <br />_-_MN # ____-----Larxl Use Application # <br />— [BEC!:�Dist =.c.ti-node <br />CONTRACTOR nrwl/or �� <br />�_ �/ <br />SERVICE REOUESTOR ! G BILLING PARTY Y / N / <br />DBA UN fTED Clr_7(C �IgVIA2014 reN-r4 PHONE 01 <br />HAILING ADDRESS ��� o <br />Tf,-s-r FAX # ( ) <br />CITY �(C�NC, STATE ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />;PIIS/17111) hourly charges nssociated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />'Paae 1 of this form. <br />also certify that I have prepared this application and that the work to be performed will be done in accord �Yi6AN <br />i <br />7 <br />JOAQUIN COUNTY Ordinance Codes and Stair;'�ds, State and Federal laws. RECEIVED <br />APPLICANT'S SIGNATURE ! <br />Date: � » � SAN JOAQUIN COUNTY <br />T i t I e: — 5 PUBLIC HEALTH SERVICES <br />ENVIRONMENTALLHEALTH Dd� ISION <br />AUTBOR17ATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, <br />the property located at the above site address hereby authorize the relense of any nrxi all results, geotechnical date and/or <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC BEALTH SERVICES ENVIRONMENTAL NEALTN DIVISION as soon as <br />it is nvailnble and at the same time it is provided to me or my representative. <br />Nature of Service Recp,est: <br />Assigrred to Employee <br />Date Service Canpleted <br />Fee Amrn.mt I Amount Paid <br />a3 (4' I ga3q -- <br />aFnc K SUPV <br />Further Action Required:/ Y) / N <br />Service Code V 'ff e <br />Date <br />PROGRAM ELEMENT 3 p <br />Date of Payment Payment Type Receipt # Check # <br />% 33zz <br />ACCT a�/ / i I UNIT CLK <br />Recvd By <br />