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FTvoe of•Bus <br />SAN JOAQ COUNTY ENVIRONMENTAL HEAL': APARTMENT <br />SERVICE RE' QUEST <br />CONTRACTOR / SERVICE RE <br />B1LLIN.0 ACKN0njjK i_lrE- T: I, :the undersigned pi operty or business owner, operator or authorized agent of same, <br />acknowledge thatrall site and/oi#oject specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me:or_:my.business.asadentified..on.this form - - <br />Ialso that I.have:prepared _this=application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Jrdinance,'Codes, standards, STATE and FBDER9.L laws. a <br />A!'PLICANVS�IGNA.TPU Imo. DATE: <br />;--?— .. <br />-AUNGLI 11tt01'E2TX/1UNIS5 OWNER':4TGR/EPfU " A N <br />If APPCIC4A .is not•the BH.Lwd PARTI proof of authorization to sign is required Title <br />r�UTIIORiZ� TION TO RELEASE Tl�1p:UT21�'IA, it31�t When applicablez IZ Elie -owner ox_o eratbr of thepr6P t� located at the <br />above site ddr� ss, -hereby _authozize die release , of ;any ;and..,al�-rests; •.geotec . cal ,data .an o- % "r -.environmental/site assessment <br />uformation to the SAN.JDAOUD COUNTYEW-moNMENTAL FIEALTH DEPART1 mNT-as soon as itis available and at the same.time it is <br />- 1 <br />'Date Service Compl , ed (if already ompleted): SERVICE CODE: <br />Fee Amou.t. Amount Paid . • <br />. - .. i_� > �.Cj .��- 7S 0. � .... f?ayment Date <br />Payment Type; Invoice # ,. Check,#' ^� <br />PIE.,.23pg 1. <br />'�7 3 <br />eceived By: <br />