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Type of u iness lk�op.erty <br />OWNER/ <br />SERVICE REQUEST <br />k / FACILrrY ID # 2 J <br />FA 000 ?� <br />FAcam NAME r <br />SITE ADDRESS n�" <br />`"T`Tl. 2rse, NurM r Wresoan <br />Mailing Address (if Different from Site Address) <br />CITY <br />PHONE #2 F'rT <br />REQUESTOR <br />Strw Nam <br />APN # <br />JBOS:DISTRICT <br />CONTRACTOR/ SERVICE REQUESTO R <br />a <br />SERVICE REQUEST # <br />5L�o <br />BILLING PARTY ❑ <br />SUN@! <br />STATE ZIP <br />LAND USE APPLICATION # <br />LacATION CODE'. <br />BWNG PARTY <br />BUSINESS NAME Fh, <br />PHo f �T• <br />MLI V fJ <br />MAtLU1GADORES 35 i, r, 1 FAX# All <br />CITY ATE ZIP g <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent at same, acknowledge U}at an site and/or project speciric <br />PUBLIC HEALTH SERVlGES ENVIRONMENTAL HEALTH Dm51oN hourly charges associated with this projector activity will be billed to me or my business as idenCified on this form. <br />also certify that 1 haveprep this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinanco Codes. Standards, STATE and <br />FEDERAL laws. <br />APPt1CANT SIGNATURE: DATE: D 11 <br />PROPERTY IBUSINESS OWNER 0 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />YAPmxmr rr not Me BRtrrc P wr r pool of m1hori adon to sign is mquhvd ri l to <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable. I, the owner or operator of the property located at the above site address, hereby authorise the release of <br />any and all results, geotechnical data and/or envlronmentallsite assessment information to the SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMCHTAL HEALTH DMSION 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: <br />F)AYNAENT <br />RECEIVED <br />AUG - 9 2002 <br />&AN JOAQUIN cOUNTY <br />pUBLiC HEWH SEAV1Ci S <br />MiJIpONMENIk KAI.iH DWj5 QN <br />r'nuroarYnv'e SIl:uAnIRF' <br />APPROVED BY:. )t�.6 s� <br />C <br />EMPLOYEE#: IF& Ll <br />DATE: 2(/9 7� <br />C� <br />i ` <br />ASSIGNEDTO: 4/1,2 <br />EMPLOYEE#: <br />C) <br />DATE: <br />Date Service Completed (if already completed): <br />Sl RvtcE CODE: <br />P ! E: O <br />Fee Amount: Amount Paid / 7 <br />Payment Date <br />Payment Type `� <br />lnvaice # Check f1 <br />I_ <br />'Received 8y: <br />