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Type of Business or Prooefty <br />OWNER I OPERA <br />AC:LfTY NAME <br />,APPROVED 9Y: <br />31TE.ADORESS- <br />DATE: <br />umtyt <br />'Railing Address <br />(If Different from Site Ad <br />EXT. <br />PHONE n� <br />ucs. <br />PHONE K2 <br />SERVICE RECUEST <br />FACILITY 10 T <br />!.L <br />A P N 4 <br />BCS DISTRICT <br />CONTRACTOR SERVICE REOUESTOR <br />SERVICE REQUEST <br />BILLING PARTY ] <br />14 Pi✓ I 7ro. <br />STATE ?IP <br />,_140 USE APPLICATION K <br />LOCATION CODE <br />BILLING <br />smu l <br />REQIIF.S70R7� <br />PHONE j <br />?USINESS NAME <br />FAX I <br />'RAIUHG ADDRESS / <br />2,1; <br />S STATE <br />QTY 'GS �'� C <br />i; <br />u cZa es assor�ated wdh MLS project or aaivdy wIY be billed to me or my business as Identified on this form. <br />BILLING AC}(NOWLEDGE?r1ENT' I. Ne :rnoers>g� horOPemt9r °usiness owner, operator or authorized agent of same, aomowiedge Nat ad site andlor prolecx spec Ic <br />?'J6L'CF'E+LiHSERVICZsErvIRCNW-NIALHEALTHOros nY <br />I also cef-MY Nat I have Prepared Nis APP <br />licalion and Nat Ne work to he performed wul be done in a=rdana: �+rlih all SAN JOAQuw COUNTY Ordinance Cues, Standards. <br />STATE an <br />=DERAL laws. <br />DATE: <br />APPUCANT SIGNATURE: <br />OPERATORMAAr+AG`cR ] OTHER AUTHORtLOAGENT g� Title <br />?aCPERTY / BUSINESS OWNERQ of --don fu �n a ^V� <br />1 Ava�r�.rr is not Vie L"Q X°Ot <br />p e located at the above site address. hereoy authorize the release °I <br />AUTHORIZATION TO RELEASE INFORMATION: 'Nhee at aot� t �e owner or operator of UI property <br />any and all re5ult5, geotecnnical data and/or ennrt:nmentaVsite reoresen��id moon N Ne $,W JOAOUW OouNrr PUBLIC HEALTH SE`A`S `4ytRCNME*lTAL HEAL -CH DIVISION as soar <br />,r ;� n.,2iunlP Ann at the same lime it is Provided to me or my <br />T'iPE OF SERVICE REQUESTED: <br />COMMENTS: <br />!NS?EC'OR'S SIGNATURE: i <br />,APPROVED 9Y: <br />_ <br />EMPLOYE= n: <br />DATE: <br />ASSIGNED T0: <br />• <br />Date Service Completed (If already comoleted): <br />=ee Amount: <br />I' <br />JERVIDE CODE: <br />Payment Type <br />I Invoice 4 <br />.ALO 3 �� <br />s^t: IGFOt, k C ?LINT <br />rUEi; : `+.EALTt�. SENJ,C£S <br />NVIPCvti1Fr�', *=• tri -I r?NISiCr. <br />CONTRACTOR'SSIGNATURE: //:! <br />_ <br />EMPLOYE= n: <br />DATE: <br />S�1pLOYEE R % <br />!DATE <br />JERVIDE CODE: <br />Amount ?aid �`Payment <br />Date l <br />Check <br />l� <br />Received By:L <br />i <br />