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r SERVICE REQUEST CEN 00 61) Revised 8/23/93 <br /> LLL <br /> TY ID # RECORD ID # O 1 L} INVOICE # <br /> ACILITY NAME J wy -5 EXXON BILLING PARTY Y / No <br /> '. <br /> SITE ADDRESS <br /> CITY 0 CA ZIP 'T5- 3 -30 <br /> of C O- rO't, D ;r- Gt/ BILLING PARTY Y / <br /> DBA PHONE #1 14 <br /> ADDRESS �- rJ O X 0 ;7- a PHONE #2 ( ) f3�3- 3 <br /> CITY CL in 12 C 0— STATE L G`t' ZIP 9 5 3 3 <br /> APN # Land Use Application # <br /> ,F <br /> F SOS Dist Location Code <br /> ONTRACTOR and/or _ t-N- -�- <br /> SERVICE REQUESTOR L�! t-2 IL Co-o /-T L a C/O y'S —T 2l c , BILLING PARTY <br /> DBA CIL ( 1 ( PHONE #1 (1,0_ )4 l - (o -3-3 f <br /> MAILING ADDRESS oL.s 3 VI/ 9 W a- m' V' V e FAX # (ILL) 3 <br /> CITY STATE CA ZIP / <br /> iLLING ACKNOWLEDGEMENT: I, the undersigned owner, operator -)r agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Sta rds, State and Federal laws. YTv`,E <br /> NT <br /> i T D <br /> APPLICANT'S SIGNATURE JAN 2 <br /> Title o 2 c- Date: <br /> ate• <br /> SAN JOAQUIN GO UNrt <br /> PUBLIC HEALTH SERVICES <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, pp@IrkligplB►ITA9�d6tiLbM�i1d #Qlbf <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: Service Code <br /> Assigned to ,�) 1'V &")-t, Employee # Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> EE <br /> C• h / SUPV / / ACCT —/-/::Al <br /> / / UNIT CLK _/_/ <br />