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• PAYMENT <br /> pr' ''lr-sp;y t"� <br /> SE0 `REQUEST EH0061SR revised 07/10/98 <br /> Type of Bus sstor Property JAN 2 1 WILITY ID# SrJC REQUE T <br /> CgA <br /> ��»ataul;v COUNTY <br /> OWNER I OPERATOR \/ <br /> / b PUB r; LTH SE BILLING PARTY 9— <br /> FACILITY NAME l[ <br /> Gff V KC*4 <br /> SREADDRESS 3355 1 rA51 I,�I�IE' <br /> Street Number Direction ' "�- Street Nam S l/�V, Type F Suite x <br /> Mailing Address (If Different from Site Address) <br /> CITY I I <br /> STATE /^ ZIP <br /> PHz E#1 C>C> CLAN-R EZdIJE N# <br /> 7 <br /> PHONE#2 aT- BOS DISTRICT LOCATION CODE <br /> �Z �z g5 Z g <br /> E� c� CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTDR <br /> R L A r2- t cf <br /> BILLING PARTY <br /> BUSINESS NAME PHONE# Ea. <br /> L NL o (- 1 C(X> zzb <br /> MAILING ADDRESSFAX# <br /> t_ L (7-7) > <br /> Lc'ry P15 A-I U F 1 e STATE t/ LP ft 9 5-1 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY <br /> Ordinance Codes,Standard and FED�R{+L laws. t4&\42 3/q o N 5WOMITPA- <br /> APPLICANT SIGNATURE: -Y(��j.Jflrj(,l•. .4 DATE: 5AH 15.1 aJ'�) 2�/��C�3HL7M--- <br /> PROPERTY/BUSINESS OWNER Cl OPERATOR/MANAGER ❑ OTHi®rrza <br /> RIZED AGENT � L b�G 6p4 Tt d <br /> IfAPPucAmT is not the BwNG PARTY pro`BTiif'don $ISH genreTitle <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, 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 environmentaVsite assessment information to the SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH 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: �-� / AFGK ' t 5 <br /> COMMENTS ❑ SPECIAL CONDITION(S)OF APPROVAL❑ OTHER ❑ <br /> tl_ <br /> INSPECTOR'S SIGNATURE: ? CONTRACTOR'S SIGNATURE: DATE: <br /> i <br /> i <br /> APPROVED BY: EMPLOYEE# DATE <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> i <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid 3 Payment Date <br /> Payment TypeInvoice Check# Received By. <br />