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GLlMr.1CR ravicPH nQ/nd/QR <br />Type of Business or Property II <br />vu. <br />FACILITY ID # SERVICE REQUEST # <br />7 <br />COMMENTS ❑ <br />SPECIAL CONDfiION(S) OF APPROVAL ❑ OTHER <br />Pg <br />OWNER/ OPERATOR <br />'4'HIEV <br />BILLING PARTY ❑ <br />FACILITY NAME A�GI/C�. <br />G/ c <br />SITE ADDRESS <br />d Street Number Direction <br />Street Name <br />Type Suite # <br />Mailing Address (If Different from Site Address) <br />DATE: <br />APPROVED BY: <br />COY 15T��7d� <br />STATE <br />LP <br />PHONE #'I / <br />APN� 170 - a ) <br />LAND USE APPLICATION # �- <br />PHONE #2 Ems• <br />� <br />Date Service Completed (if already Completed): SERVICE CODE: J 3 / P 1 E: d 3 0 <br />DISTRICT <br />f <br />LOCATION CODE <br />r•naTae('TnR t SFRVICtS REQUESTOR <br />REQUESTOR CSOY ` 1 <br />BUSINESS NAME / 6 PHONE# <br />4!�2 E 7 TL4EC- C.! ��l . <br />MAILING ADDRESS FAx # <br />leiN7 <br />CITY 'ra g (—J / J STATE G <br />BILLING PARTY LSC <br />EV. <br />sSl-�`s <br />Ir- Yl3- 'fs'l7 <br />ZIP A L -L t -7 -9 -- <br />BILLING <br />-7.o - <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or autnonzea ager,a V1 D4111C„ <br />and/or project specific PUBLIC HEALTH SERvicEs ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to <br />me or my business as identified on this form. <br />I also certify that 1 have prep red this application and hat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br />Ordinance Codes, Standard STA and F ERAL la <br />APPLICANT SIGNATURE: DATE: <br />PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER A <br />OTHERAUIHORIZEDAGENT ❑�N SNIfAPPUCANT is not the BILLING proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, <br />hereby authorize the release of any and all results, geotechnical data and/or environmentaYsite assessment information to the SAN JOAQUIN COUNTY <br />r , Cl---1=—,,0nn1uFWT01 HFAI TH DIVISION as soon as it is available and at the same time it is provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />a s / :;, , <br />7 <br />COMMENTS ❑ <br />SPECIAL CONDfiION(S) OF APPROVAL ❑ OTHER <br />Pg <br />w)e-4C-7 <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />DATE: <br />APPROVED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED T0: <br />EMPLOYEE #: <br />DATE: <br />� <br />Date Service Completed (if already Completed): SERVICE CODE: J 3 / P 1 E: d 3 0 <br />Fee Amount: �� �, <br />Amount Paid ,1 <br />Payment Dae o`er- Q8 <br />Payment Type <br />Invoice <br />Check # (W,3 q e1 6 <br />Rec, By <br />