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r SERVICE ...:1ItcST <br /> Type of Business or Property Si I FACILITY ID#� �� SERVICE REQUEST# '' `` <br /> 6 re ��i is U)I O Gu 1 �� 4 � -54 <br /> OWNER/OPERATOR BILLING PARTY'_, <br /> 1 L <br /> FACILITY NAME <br /> 14_) <br /> , �y a,I �S C�C <br /> SITE ADDRESS KJ <br /> IV Street Number Dir n Street Name Type Suite# <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR �►lJ BILLING PARTY <br /> - u <br /> BUSINESS NAME PHONE# ExT• <br /> MAILING ADDRESSFAX# <br /> ee � <br /> 3 Sdt -bfu6L <br /> eSf CITY S o-G Oct STATE P zip C <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly Charges associated with this project or activity will be billed to 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 Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C <br /> If APPLIGWT is not the BILLING PAR TV 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,hereby authorize the release o <br /> any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DI`11SION as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> ' COMMENTS: IrAN MENI <br /> RlFr I <br /> JUL 21999 1 <br /> I <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVIS!Ot, <br /> INSPECTOR'S SIGNATURE: D� ��P' C CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: I ES''LOYEE#: DATE: Z �( <br /> ASSIGNED T 0: EMPLOYEE#: 000 k1 DATE: <br /> Date Service Completed (if alrea y ompleted): SERVICE CODE: d' P 1 E: <br /> Fee Amount: CL)VAmount Paid i Payment Date <br /> Payment Type Invoice# Check# Received By: I <br />