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a.SERVICE RECO <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Imin ► r � <br /> OWNER/QPF,RATORli � ^ �� BILLING PARTY[IFAcnRY NAME I_ll' b r Ll ilJ• ISS <br /> SITEADORESs <br /> Mailing Address (If Different from Site Address) <br /> CITY /� �J., STATE ZIP <br /> P(dfNE#1 ¢sa- i J35 APN# LAND USE APPLICATION# <br /> PHONE#1 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> u ve�tf <br /> BUSINESS NAME Pn h n V ,'^G, �`. <br /> MaILINGADDRESS VY,wAire �t�LL �(� !— FAX# <br /> CITY STATE /T'!/1 ZIP Q5✓� �p <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business ovmer,operator or authorized agent of same,acknowledge that at site ardor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH ONMSgN hourly Charges a55 ladl with this project or activity will be biAed to me or my business as identified on this form. <br /> I also certify,that I have prepared this application and that the work to be dammed will be done m accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAI.Iaws. <br /> APPLICANT SIGNATURE: �'�u ��� DATE: <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAeRX1Wmrntthe BLLMPA ,poor ofwdmrlkadon to sign is/sound Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above she address,hereby author®the release of <br /> any and all results,geotechnical data ardor environmentatsite assessment information to the SAN JOAQUIN COUNTY PueLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as t is available and at the same tine t is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: - ^ (7 <br /> COMMENTS: <br /> PAYMENT <br /> DEC 7 1998 <br /> SAN JOAOUIN COUNn, <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSPECTOR' CpMRACrOR's SIGNATURE: <br /> APPROVED HY: EMPLaymt QDO DATE: I <br /> ASSIGNED TO: EaddiUmEE& DATE: <br /> Date Service Completed (if already completed): - SERVICE CODE (� 'P IE:.2„ <br /> Fee Amount: Q oC (9C) Amount Paid Payment Date / <br /> Payment Type Invoice# Ciel*If Received By: <br />