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Type of Bu�ness or Property' SERVICE REQUEST <br /> FACILITY ID# <br /> SERVICE REQUEST# <br /> OWNER/OPERATOR S� <br /> BILLING PARTY Q ` <br /> FACILITY NAME <br /> SITE ADDRES P <br /> r iI Number OjiHyy� <br /> Mailing Address (If Different from Site Address) a Type <br /> Sull"K <br /> CITY <br /> _ STATE ZIP <br /> PHONE99 _Fxr. APN <br /> 6n(f� I�n/��./ 1 LAND USE APPLICATION 9 <br /> PHONE#2 (� r { <br /> 8OS:IJISTRICT ;'`: <br /> ::. LOCATIOR.COp <br /> . . E <br /> CONTRACTOR 1SERVICE REQUESTOR <br /> fREQUESTO <br /> BILLING PARTY` <br /> I3USIHESS N PHONE# , <br /> Ft&LlNGPAMDR VSS r" G FAx# <br /> �'f "2 <br /> 6213 <br /> STATE ZIP <br /> v <br /> BILLING ACKNOWLEDGEMENT; t, the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project spedric <br /> PUBLIC HEALTH SERVICES ENVIROnmENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identirred on this form. j <br /> I also certity that I have prepared this application and that the work to be performed will be done in accordance with an SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE. DATE: <br /> PROPERTY I BUSINESS OWNER 0 0 TORI MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> YAPRf1C.W r is not the({ujvg�ur_r proof Of aufhorui floe to sign is rvQuirnd 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 environmentallsite assessment information to the SAN JQAQUIN COUNTY PUBLIC HEALTii SERVICES ENVSRONMENTAL HEALTH DmSIGN as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICC REQUESTED: <br /> UA <br /> COMMENTS: <br /> t <br /> r <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: " <br /> APPROVED BY:. EMPLOYEE#:2 <br /> 1 1 J DATE: <br /> A551GHED T0: EMPLOYEE#: J DATE: <br /> Service Completed (if alrca omplcted): -- <br /> Date P!E_'20 <br /> � v?, <br /> ( ;L7 SERvrcE CDOE: ./ <br /> Fee Amount: Amount Paid Payment Date lel�a Do <br /> Paymcnt.T,ypc invoice#' Check tf <br /> Received By:v�/�,r.,� <br />