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0 0 <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REQUESI UK <br />REQUESTOR BILLING PARTY ❑ <br />BUSINESS NAME <br />MAIUNG ADDRESS <br />CITY <br />PHONE # EXr' <br />FAX # <br />STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />Pusuc HEALTH SERVICES ENviRoNMENTAL HEALTH OIvism hourly charges associated with this project or activity will be billed to me 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. � ,Q <br />APPUCANTSIGNATURE: `��� T' �` DATE' <br />OPERATOR/ MANAGER Q OTHER AUiHORQED AGENT <br />PROPERTY/ BUSINESS OWNER p <br />If APPLC+wr is not U*8tl11NG Parry proof of autharizatlon to sign i5 nxryirad 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 environmentailsite assessment information to the SAN JOAQUIN COUNTY PUsuc HEALTH SERvicEs ENvtRONmwAL HEALTH OMSION as soon <br />.,..a .,* a.e ­. rrmp it is nmviripd to me or my reoresentative. <br />