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Type of Business or Property SERVICE REQUESTFACILITY ID# <br /> SERVICE REQUEST# <br /> OWNER I OPERATOR 0 C <br /> 1 L Xci /Z'-OQBILLING PARTY O <br /> FACILITY NAME <br /> SITE ADD ss <br /> 6treet Number arection G ���/ <br /> Mailing Address (If Diff It fro Site Address) <br /> Trr swu r <br /> STATE Zip <br /> P)IONE 91 IY// <br /> 7 <br /> r"T• APN� 71JNDsE APPucAnolr# <br /> ( ) <br /> PHONE#2 W. <br /> JBOS DIST1tIcr <br /> LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> BILLING PARTY l <br /> BUSINESS NAME PHONE# . <br /> ' 2-P93/ —X375 <br /> MAILING ADDRESS FAx# <br /> CITY 5 <br /> ,S C /< h9 c STATE �� ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, acknowledge Urat all silo and/or project specific <br /> PUBLIC HEALTx SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this fomi. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance wiUl all SAN JOAQUIN COUNTY Ordinanco Codes,Standards,STATE and <br /> FEDERAL laws. A <br /> �APPUCANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER O OPERATOR/MANAGER ❑ OTIIERAUTHORIZEDAGENT ❑ <br /> If Avrt.r..wr is rut(ho QUm pNz proof of authorization to slpn Is requGvd T i t l o <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 andlor environmentaUsito assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALm SERvicES ENVIRONMCNTAL HEALTH DNISION 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 /> Si�( Gcr� �i ibSGcl-'mac{CCS C ca w.i vt C-- (�9 liLL7c� <br /> COMMENTS: <br /> 'AYMEN <br /> L RECEIVED <br /> 0- 1102001 <br /> :U N C LWTY <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVEDBY:. ��-�� EMPLOYEE If: � DATE: 11 <br /> ASSIGNED TO: ; 1 EMPLOYEE 1 L L DnrE: <br /> Date Service Completed (i(alrca completed): SERVICE CODE: 1 PIE:--) <br /> Fee Amount: �'— Amount Paid r 4 Pa ment Datc 1 D <br /> I l ,� y 11 <br /> Payment Type f Invoice#• Check# Received By: i <br /> y <br /> .d <br />