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L� SERVICF,°EQUE'S rr' <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 ER(OPERATOR BILLING PARTY 0 <br /> tN <br /> N�\V-x-- <br /> FA SITE ADDRESS <br /> �2�0 Smred Number -:T. <br /> ype Suits 3 <br /> Mailing Address (if Different from Site Address) <br /> CITY STATE ZIP Q52C3� <br /> PPNE14ONE#1 �- APN# LANo USE APPUCATION# <br /> PHONE#2 err. BOS D1sTRICT LOcATIOM COoE; <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR SUING PARTY <br /> BUSINESS NAME _ ONE# \ T <br /> MAILING ADORES � �\ � \y AX# �• ��� <br /> Ctrl (� STATE ZF <br /> BILLING ACKNOWLEDGEMENT: i,the undersigned property or business owner,operator or authorized agent of same,admowtedge that ad site and/or project specific <br /> Puauc HEALTH SERVICES EwRoNmENTAL HEALTH DIVISION hourly charges associated with this projector activity will be billed to me or my business as identified on this forth. <br /> I also certify that I have prepa this application and that the work to be performed w�be done in accordance with au SAN JOAOUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE \2 <br /> PROPERTY/13USINESS OWNERO • OPERAT /MAtRACER OTHER AuTHOR�D AGENT <br /> it nit 8wnc Purr proo/o/wthorfntfon to sign is nquin Tit f <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,.),the owner or operator of the property boated at the above site address,hereby authortm the release of <br /> any and all results,geotechnical data and/or environmentallsite assessment information to the SAN JOA"COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 /> COMMENTS: <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: EmPL^.Y--t DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (d already completed): SERVICECODE: .- P fE:. <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By- <br />