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71 <br />Type of Business or Property <br />OWNER I OPERATOR <br />FACILITY NAME ��� <br />G <br />SITE ADDRESS ¢3aZV <br />Street Number <br />Dion <br />Mailing Address (If Different from Site Address) <br />�S <br />CITY <br />PHONE #1 <br />33�—�9 <br />EXT. <br />clod � <br />PHONE #2 <br />Er' <br />SERVICE REQUEST <br />FACILITY ID # <br />APN # <br />Street Name <br />BOS DISTRICT <br />EH0061 SR revised 09/04/98 <br />SERVICE REQUEST # r>1 <br />BILLING PARTY !Sd' <br />Suite # <br />STATE A LP <br />LAND USE APPLICATION # U <br />I <br />CONTRACTOR l SERVICE REQUESTOR <br />LOCATION CODE <br />REQUESTOR BILLING PARTY ❑ <br />BUSINESS NAME PHONE ' <br /># <br />MAILING ADDRESS /L 1 FAX # % 717& <br />CITY / J STATE d LP/ <br />..i.. a,.,. as,..♦ .,u sae <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent or same, aCKJlowicuyc ,,,a. o,. to <br />and/or project Specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project Or activity will be billed t0 <br />me or my business as identified on this form. <br />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, Standards. ST and FEDERAL laws. <br />APPLICANT SIGNATURE: DATE G `Y <br />PROPERTY/ BUSINESS OWNER ElOPERATOR / MANAGER C1 OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY 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 environmentaUsite 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: \ <br />COMMENTS ❑ SPECIAL CONDITION(S) OF APPROVAL ❑ OTHER ❑ <br />INSPECTOR'S SIGNATURE: <br />APPROVED BY. G <br />ASSIGNED TO: <br />Date Service Completed (if already <br />Fee Amount:7)t� <br />Payment Type <br />-�—u <br />Invoice # <br />PUBLIC HEALTH SERVICE; <br />ENVIRONMENTAL HEAL T7i DIVIS,,j,, <br />CONTRACTOR'S SiGNA. JRE: DATE: <br />EMPLOYEE#: 03 DATE: <br />EMPLOYEE #: DATE: <br />SERVICE CODE: P 1 E: <br />Amount Paid yea 3 �/ , Payment Date y a 3 CJS <br />Check I Received Sy: `I. <br />