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• SERVICE REQUEST CEH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # G INVOICE # V <br /> lJ �/ <br /> FACILITY NAME �1�1 �I-�J�� S ��S�� f BILLING PARTY Y / N <br /> SITE ADDRESS 1(2900 f� <br /> CITY O C�! CA ZIP �✓ <br /> WNER/OPERATOR llN/^�l�G(�/ /QK�t 1 �G� / I Cys© K Q BILLING PARTY ( Yl / N <br /> DBA / Iy / l O !G �' /�l if` i S� / 1 Cf S ! ! S PHONE #1 ( <br /> -7,C"7' <br /> ADDRESS l U T �� �d"� ���� L'I L ` ��/ PHONE #2 ( ) <br /> CITY C7�/ STATE Com— ZIP <br /> APN # Land Use Application # <br /> IFBOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR (/ co / BILLING PARTY Y / N <br /> DBA /"/ / l a �d�e / 'fS '( ! GS �� S PHONE #1 (.::�Cl? ) <br /> MAILING ADDRESS 1(2 !E 26 C? �UGZ �/ l�Cl FAX # <br /> CITY C/I (I 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 bitted to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> PAYMENT <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordancIpUit Fa'Hrsa <br /> =JOAQUIN COUNTY Ordinance Codes d Standards, State and Federal taws. A U U 2 11995 <br /> APPLICANTIS SIGNALURE SAN JOAQUIN COUNITY <br /> PUBLIC HEALTH SERVICES <br /> /� � j ENVIRONMENTAL HEALTri DIVISION <br /> Titles./©• `/� W !1 -e Dater/ <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 /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request:/ Lit.. Service Code S� <br /> Assigned to w< IIVZI�(C6 J� 4 C Employee # 7 Date ,4/.2 <br /> Date Service Completed -/-/ Further Action Required: Y / N PROGRAM ELEMENT 14 D <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> v�o 7t . < 'q� 4 l 7 S {� <br /> REHS / /� SUPV _/ / ACCT U / UNIT CLK _/ / <br />