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SERVICE REQUEST (ER 00 61) Revised 81Z3- <br /> RECORD 10 0 INVOICE N <br /> FACILIfy Ito) ON -7 O'b <br /> FACILITY WAMV. ATZC0 _AM4PM CA BILLING PARTY Y. 0 <br /> - <br /> S17E ADDRESS 2470 Grant Line Road <br /> CITY Tracy CA ZIP_ <br /> OWIER/OPFRAtuit ATLANTIC RICHFIELD COMPANY,,. Illy 9 <br /> oa,k ARCOPRODUCTSQQMPANY PHONE 91 <br /> CENTERPOINTE DR. PHONE 02 <br /> CITY LA CA PALMA STATE z I P 90623 <br /> AVN Land Use Appticntion 0 8US asst Location code <br /> CONTRACTOR and/or <br /> SNot Selected at this time. SILLM PARTY <br /> MICE REQUEStOR <br /> USA PHONE N1 <br /> MAILIRG ADDRESS FAX ft <br /> C17YSTATE ZIP <br /> --PAYMENT <br /> nc <br /> BILLING ACKNOWLEDGEMENT- 1, the undersigned owner, operator or agent of tame, acknowtedge that ail SI Mor project specific <br /> PHS/EhO hourly charges associated with this facility or activity wilt be bitted to the partyI t th BILL104G PARTY on <br /> Page I of this for-I". <br /> SAN <br /> thin PL�O S <br /> I also certify that I have prepared appticittion and that the work to be performed wiltPL <br /> YM W461F Ttwe with all SAN <br /> ENVIRONMENTAL RV(C�l <br /> JOACUIN COUNTY Ordinancedards, Federal laws. HEALTH DI <br /> �e_ Stan VISION <br /> APPLICANT'S SIGNATURE : <br /> Permit Agent Date- -7 Zq <br /> AUTHORIZATION TO RELEASE INFORMATIM: In addiflon to the above, when nPpkfcrA)kC, 1, the owner, operator or agent of some, of <br /> the property located at the above site address hereby authorize the release of any and oil results, geotechnical date and/or <br /> envjrogvirnt9t/qite vsqervziorvt information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EIJVIR0U14ENTAL HEALTH DIVISION a$ soon As <br /> it is available and at the same time It Is provided to = or rly representative. <br /> Nature of Service Recluest, '41 or% service Code _U <br /> 7- <br /> Assigned to Date <br /> 0 Eaptoyee /—=1 - <br /> ... 3 1 <br /> Dnte Service Completed Further Action Required: Y 14 PROGRAK ELEMENT-2 <br /> Fee Amount Aoxxint Paid Date of Payment Payment Type Receipt N Check 0 Recvd By <br /> 1-—7RTG 627-25,5- <br /> OV 6 <br /> "Ijpv ACC I UNIT CLK <br /> 'd Nod-4 NdEZ: L L661-60-L <br />