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c (�o wr-� � d q �p <br /> 10-10 k7� ( 5 SERVICE REQUEST (EH O(1 61� i�sed 8/23/93 <br /> FACILITY ID # 7 S RECORD ID # �/��_ INVOICE # 3 3� <br /> FACILITY NAME 7-1"OC 5"' �� �c �1 / ��C�[/ Il BILLING PARTY Y <br /> TraXTee 7-ra1 <br /> SITE'ADDRESS 34 7 a 3 111.4 C A e -A(a C 0,t <br /> CITY �I _��rJ C14 CA Z!P <br /> OWNER/OPERATOR /� C Y �`/� 7°�� �' ��C�y'= `� BILLING PARTY J T / N <br /> I IVC <br /> DBA PHONE #1 <br /> ADDRESS 0 G 3 1 P Tf4 61 p PHONE #2 <br /> CITY ( / STATE t4 ZIP / 3 <br /> APN # —Land Use Application # — <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING PARTY Y / N <br /> DBA PHONE #1 <br /> AILING ADDRESS _ FAX <br /> CITY STATE _ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or 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 /> .'r <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. S�r) <br /> APPLICANT'S SIGNATURE : �Zf��(/t ff 3 199 <br /> -Gf�`— J, <br /> 48&p3'' ""CNE. C71i1 CC`'A <br /> Title: c�ir� �cvrG► r�, C( /v ✓ Date: / — Z3 / � EY(V/jMFrVZ- <br /> H�SE�V)CES <br /> EAS Ty DIVr� <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, I, the owner, operator or agent of s Aof <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: 50 s L, Service Code <br /> Assigned to m r-JEmployee # Date __2_/ .2- <br /> Date Service Completed / /_ Further Action Required: Y / N [7PRO7GRAMELEMENT _ <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> 3 7d 00 390 dJ `/' 023 6 ,j 4 Ig5,(q <br /> RENS 41/ / SUPV __/ / ACCT D 9 / S /��/ TUNIT CLK _/ / <br />