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Type of Business or Property — L OWNER I OPERATO FACILITY NAME SITE ADDRESS Mailing Address (If Different from Site Ad SERVICE REQUEST FACILITY ID "» CITY APN # PHONEi 1&o 45YJ 80SDISTRICT EXT. PHONE #2 CONTRACTOR I SERVICE REQUESTOR SERVICE REQUEST 4 l/ '5/9 7 �/ BILLING PARTY STATE ZIP LAND USE APPLICATION # C`' LOCATION CODE BILLING P REQUF.STOR Gg 7h T i/ _l - PHONE BUSINESS NAME fi G' f_....--��1C �Gl -l' l /.2^� Fax# MAILING ADDRESS J STATE j/ f ZIP --------------- ge that all ite andlor project `ACKNOWLEDGEMENT' I, the unaersigned property or business ovmer�operator or aagtv�itywil be billed to me oed agent of rmy usiiness as dentifised on this form. SpPGfic BILLING PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges assocaled project 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 Ordinance Codes, Slanaards, STATE and FEDERAL laws. j DATE: J APPLICANT SIGNATURE: r" f7 ❑ OPERATOR 1 MANAGER ��, OTHER AUTHORIZED AGENT � i i II e PRCPERTY / BUSINESS OWNER �q Proo101 wthorizadon to sign is nW� r1 Avar c wr is not the 13St AUTHORIZATION TO RELEASE INFORMATION: When applicable, f, the owner or operator of the property located at the above site address, hereby authorize the release o any and all results, geotechnical data and/or enwrCnmentaitsite a en �n�to TTm bon to the Ski JOAQUW COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OtvIs10N as soon as it is available and at the same time it is provided to me or rrry p TYPE OF SERVICE REQUESTED: -- COMMENTS: ' INSPECTOR'S SIGNATURE: APPROVED BY: ---- ASSIGNED T0: Date Service Completed (If already completed): -7 r Fee Amount: Payment Type I Invoice CONTRACTOR'S SIGNATURE: - " w'N 3I ;+, EMPLOYEE�: _ DATE: S"i , .. R: DATE: CONTRACTOR'S SIGNATURE: - " ' -1 - " EMPLOYEE�: _ DATE: (p R: DATE: EMPLOYEE SERVICE CODE: /7 Payment Date I 7 Amount Paid ' v Received I Check ! j PIE: