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SERVICE REQUEST 10 (EH 00 61) Revised 8/23/93 <br />FACILITY ID # RECORD ID # 2 INVOICE # OL�j <br />FACILITY NAME <br />SITE ADDRESS 11 -7 <br />1*1 <br />BILLING PARTY / <br />CITY foo J CA ZIP <br />OWNER/OPERATOR BILLING PARTY <br />DBA l` L A L l�.A �` uc V u�4 PHONE #1 Q20 e' -I )- <br />ADDRESS \\ �� F, rAS \ L 1a Q bi ��� lAQ PHONE #2 (, VC1 ) I <br />CITY STATES ZIP <br />APN # Land Use Application # <br />BOS Dist Location Code <br />CONTRACTOR and/or l `r <br />SERVICE REQUESTOR �,.ryjam`, BILLING PARTY Y / �' w (JL-rG7( 1 N <br />DBA <br />MAILING ADDRESS <br />W <br />PHONE #1 L- 16333 <br />FAX # ( q ?4U I - <br />CITY c }II 1l"_1' )�sl STATE ZIP �✓�`�-� <br />c <br />FBILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that allor project specific <br />PHS/EHD hourly charges associated with this facility or activity will be billed to the party identij-&011ING PARTY on <br />Page 1 of this form. • ��d we <br />AU <br />I also certify that I have prepared this application and that the work to be performed will be done Th 4ccdr? with all SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. SANJOA U/ <br />ENVIRON PUIcHEAL H SRVN7Y <br />APPLICANT'S SIGNATURE \v� ��S' `ti ALHFeE.gyf <br />ISlonl <br />,Title: Date: yr ' C1� <br />QS <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of same, of <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 />ft it is available and at the same time it is provided to me or my representative. <br />Nature of Service Request: <br />Assigned to I J �%{� ►/V'L, .0-d"=,, Employee # <br />Date Service Completed / / Further Action Required: Y / N <br />Service Code <br />Date <br />PROGRAM ELEMENT <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt # <br />Check # <br />Recvd By <br />`Z. 3 <br />j el <br />Shq17 <br />v <br />Jd <br />zk <br />REHS I Q:gtf / /-r-I SUPV 149—/ / I ACCT I ( / / I UNIT CLK I _/ /, <br />