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{^ , Type of Business orSER <br /> party VIC REQUEST <br /> C ' FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR <br /> r <br /> FACILffY NAMb BILLING PARTY❑O _ <br /> SITEADDRESS <br /> $trBl Numbr Olr,ctluo G <br /> Mailing Address (If Different from Site Address) Type suile0 <br /> CITY <br /> $TATE zip <br /> PHONE#1 <br /> APN# <br /> ( '� LAND USE APPLICATION# <br /> PHONE#2 <br /> SOS DISTRICT LOCATION CODE <br /> REDUESTO CONTRACTOR I SERVICE REQUESTOR <br /> BILLING PARTY;( <br /> BUSINESS N n <br /> PHONE# E <br /> MAILING AD RESS CCC---L��� /I lw <br /> y ' FAX# /� <br /> CITY <br /> __.. TATE .. <br /> BILLING CKNOWLEDGEMENT: I, the undersgned property or business owner,operator or authorized agent of same, acknowledge that all she and/or project specipc <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION heUdy Charges associated with(his project or activity war 4' - d to me or my business as Identified on this form. <br /> n <br /> I I Also certify that I have prepared this application and that t e work to be performedµhp be done in accordance t <br /> FEDERAL laws. JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> ' t4Bf ¢. y�/ <br /> i W. <br /> APPLICANT SIGNATURE: <br /> )ATE: Z1 Jr U <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORNEO <br /> C IIAvPIT„wris net tlp PM Prcoloyaatlrodzadon „,)„d <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the ro erl ire <br /> {ttany and all results,geotechnical date and/or envlmnmental/site assessment Informatlon to the SAN JOAQUIN COUNT the above she address,hereby authorize the release of <br /> G as it Is available and at the same time It Is provided b me or my repressntatNe. the <br /> SERVICES ENVIRONMENTAL HEALTH DIVISION as Soon' <br /> tGG TYPE OF SERVICE REOUESTEDY <br /> COMMENTS: <br /> l <br /> r INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> r 'APPROVED BY: <br /> o" ^ <br /> EMPLOYEE#: <br /> ASSIGNED TO: <br /> EMPLOYEE#: <br /> bat#Service Completed (it already completed(: <br /> SERVIOI P/E: <br /> I <br /> Fee Amount: Amount Paid <br /> mt Date <br /> Payment Type Invoice# <br /> Check# Received By: <br />