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INVOICE # <br />FACILITY ID # Vv }? RECORD ID <br />FACILITY NAME <br />1-"L� U <br />_ 1"1 <br />L__.L .L <br />BILLING PARTY <br />T� <br />SITE ADDRESS <br />lY <br />CITY (-I�L / CA ZIP �I <br />OR �CQ��L��r L_ ,1, .L BILLING PARTY Y / 6) <br />DBA 1 �� L%. r'`�'� , t . C . PHONE #1 (-510) 3S - Scb <br />ADDRESS P -, �✓u �� PHONE #2 ( ) <br />CI TT STATE ZIP 9,45IF <br />� <br />land Use Application # <br />BOS Dist Location Cods <br />CONTRACTOR and/or <br />SERVICE REQl S70�R LI -8 'S I, <br />,�/{nZI'C BILLING PARTY T� I/N <br />-1AY C,, PHONE #1 (�/ ) l -2`r14C- <br />KAILING ADDRESS 3tp FAX # <br />CITTStAN i �O Ste/ STATE CA ZIP 1 5 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of sam, acknowledge that alt site end/or project specific <br />pHWEHD 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 />PAYM E <br />I also certify that I have prepared this application and that the work to be performed will be done in actor "rsm <br />JOAQUIN COUNTY ordinance Codes and Standards, State and federal laws. <br />APPLICANT'S SIGNATURE : �,� )�ih JUN 9 1999 <br />ilia: J -t3 \ ('� Date:/USAN JOAQUIN COUN i Y <br />JBUC HEALTH SE <br />ENVIRONMENTAL. HEALTH IDIVI,,c.;)i-: <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, 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 assessebnt information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />it is available and At the same tiax- it is provided to me or my reprersentativc. <br />Fee Amount <br />Amount Paid Date of Payment <br />Payment 7y Receipt 8 <br />Check IN Recvd By <br />