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SERVICE RFr]t1EST (SERVREC) Revised 8/23/93 <br /> ACILITT ID # RECORD ID b <br /> =T'22:j� <br /> INVOICE rY <br /> iClLI1T RARE <br /> SITE ADDRESS <br /> CITY SVOC_,�k CA ZiP_ t� <br /> C' 'R/OPFRAIOR t <br /> BILLING PARTY / N <br /> DBA �J PHONE *1 <br /> ADDRESS !�Z ��p�GJrr PHONE 02 ( ) - <br /> CITY y ��.�-p�` _ SLATE ZIP <br /> Land Use Applicntfon i! <br /> SOS Dist Location Code <br /> :r RACTOR and/or <br /> i£ ICE RECUESTOR !� BILL NO PARTY Y / <br /> DBA I / PHONE 01 (2�)��_� <br /> 'A.,ING ADDRESS JDH� Lt d' �/��! "��� FAX 0 � 1 1 1 r� _ t i <br /> CITY /' STATE !'* ZIP <br /> 9111-ING ACKNOWLEDGEMENT* 1, the undersigned owner, operator or agent of snme, acknowledge that alE site end/or project specific <br /> P /E11D hourly charges associated with this facility or activity will be bitted to the party identified as the BILLING PARTY on <br /> Paye 1 of this form. <br /> I so certify that I have prepared this application and that the work to be performed witl be done in accordance with alt SAN <br /> JI MIN COUNTY Ordinance Codes and Standards, State Federal taws. <br /> PAYMENT <br /> AT -ACANT'S SIGNATURE : _ RECOW0 <br /> Title. Dato:�p JUN 131996 <br /> _ <br /> At ORIZATION TO RELEASE INFORMAriow: In addition to the above, when applicable, I, the owner, �r+ tTidfM(;fiAg <br /> 0— property located at the above site address herr.by authorize the release of any and all result-geo QIIt f Td"p SJO1V <br /> xivirormental/site assessment information to SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> i` q available and at the same time it is provided to m* or my representative. <br /> Nature of Service Reglest: =Ser-fee <br /> V_ ft *f-% �: �"I'll'' hiiiici_ <br /> signed to Errptrsyee 0 .. I � Date <br /> Date Service Completed / J _-- ren then Action Required: Y / NPROGRAN ELEMENT <br /> rep Amount Amo,mt Paid Date of Pal"-Fir Payment Type Receipt # Check # <br /> Recvd By <br /> V <br />