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0 SERVICE REQUEST • (EH 00 61) Revised 8/23/93 <br /> FACILITY ID # RECORD ID # INVOICE # c,2 73 `9 d <br /> .-FACILITY NAME �A.-&.AOh �+rosa BILLING PARTY Y / N <br /> � 1 <br /> SITE ADDRESS \31D U.Gr'e'& ����'�+-�� �'"e IRECEWED <br /> CITY 1 r-A.u4 CA ZIP APR 12 1996 <br /> SAN!C, ,.�, Gii?.�N CY <br /> PUBLIC HFAI THr <br /> HUNMENTALE I_ALTH�)l 1pq <br /> (OWNE>ROPERATOR �larag �wuP BILLING PARTY <br /> DBA PHONE #1 ( 20 )_835 - 7%,Z <br /> ADDRESS 2A q 33 c�.man PHONE #2 ( ) <br /> CITY Tru± STATE Cly ZIP 95376 <br /> APN # Land Use Application # <br /> F F <br /> SOS Dist Location Code <br /> CONTRACTOR and/or _ n/� <br /> SERVICE OR and/or �" V-MNII:n l.em PAnrVic BILLING PARTY To / N <br /> DBA PHONE #1 <br /> MAILING ADDRESS P. O. ZCK III FAX # (_201 ) 7Z3 - gIZ3 <br /> CITY K-0-r—l STATE LA ZIP 553q) <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 /> OAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br /> APPLICANT'S SIGNATURE <br /> Title: Cf'Phl�eM� Date: <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: l(tti��} i���-c-� Service Code <br /> Assigned to _ " "4J �� l (t � \"� Employee # v -�� r Date <br /> Date Service Completed / / Further Action Required: Y / N PROGRAM ELEMENT �Y e <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> `�1rz19(� ✓ 3790 <br /> REHSl / / SUPV _!/ / ACCT ��/ �7 /�� UNIT CLK _/ / <br />