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WILITY NAME <br />SITE ADDRESS <br />CITY �� V / ac— ZIP _ <br />CONTRACTOR and/or � n � ` /I <br />SFRVICE REOUESTOR 1 <br />30SERVREo) Revised 8/23/03 <br />PHONE 01 ( ) <br />PHONE N2 ( ) - <br />PHONE Ni ( <br />MAILING ADDRESS �; ?-s- <br />W ° I <br />4 t 2 �� ST <br />FAX 0 ( )_ <br />CITY 4 <br />T-OP—_j] <br />STATE CI'�l <br />ZIP 32 /D- c2D I <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br />PNS/END hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br />Page 1 of 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 ell SAN <br />JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br />the property located at the above site address hereby authorize the release of any and all results, geotechnical date and/or <br />environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br />It is available and at the same time it is provided to me or my representative. <br />Fee Amount <br />Amount Paid <br />Date of Payment <br />Payment Type <br />Receipt 0 <br />Check 0 <br />Recvd By <br />