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Type of <br />OWNER <br />FACILITY NAME <br />v lar SERVICE REQUEST <br />ness or Property <br />T- _ / . \ FACILITY ID # <br />Mailing Address (If Different from Site Address) <br />PHONE#1 <br />#1 F„T <br />t ) <br />PHONE #2 <br />REQUESTOR <br />APN# <br />BIDS DISTRICT <br />CONTRACTOR/ SERVICE REQUESTOR <br />,.Or <br />SERVICE <br />LAND USE APPLICATION # <br />�Z <br />BILLING <br />zip <br />LOCATION CODE <br />BILLING PARTY ❑ <br />BUSINESS NAME PHONE // <br />MAILING 1:11:11:11; 3: ?./ 7 <br />! FAX # <br />Cm004 K6S <br />' STA zip <br />BILLING ACKNOWLEDGEMENT: I, the u ersgned Property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this pmject Or acN/ity will be billed tome Or my business as identified On 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 JOAQUIN COUNTY Ordinance Codes. Standards, STATE and <br />FEDERAL laws. D <br />b <br />APPLICANT SIGNATUREJ/ DATE:_ <br />PROPERTY/ BUSINESS OWNER El OPERATOR/ MANAGER 10 OTHER AUTHORIZED AGENT ❑ <br />If APW1CANTIsnotrhe8N pARN poor of automation W sign is raquued Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of <br />any and all results, geotechnical data and/or environmeniallsite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISCN as soon <br />as it is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />CLU `(�ti ,U�J( _ �J <br />U_ <br />COMMENTS: <br />PAYMENT <br />RECEIVFR <br />i <br />SEP 2 3 1998 <br />SAN JOAQUI14 COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />I <br />l INSPECTOR'S SIGNA RE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: � ,kms' <br />V <br />EMPLOYEE#:��'� <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: ---21y' <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />