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,00/27/2001 13:57 20946BW3 FIFTH FLOOR PAGE 05 <br />srttvlc>= PtMAJIM <br />_ G Vtd t ttAl:l Ux 1 Dl=tcVwt tctttu a� � �+.c <br />ESTOP <br />$IUJNG P*11"' 11 <br />R>:4Ua <br />PHQNE # <br />Busrarss NAME L , Je �/ <br />FAX m i <br />iViAlUNGADOIiE55 Q�--✓A . �yv- 6 9aq t I <br />Ctrr ��lr2b.4z�/K 4J - RJ STATE G� ZIP <br />BILLING ACKNOWLEDGEMGn I, the ulldeMgned Property or business owner, oPcrator Of authorized agent of same, adr:c ge ylat ail site andror prejecS spr -- <br />PtrsUc HEALTTt S=s2v10ES �r14rRCNM6tTALHEALTH OtVlsmt3 hatdychz(ges assodaied w T Ixa ocacSvAy wiA 1)e billed to me or my business as identtEed an Oris �- <br />I a -,a cenify that I have preper*d this application and that the work to be performed xitl be done in ac=dance With all SAN JCAQUIN Ca NN Ordinance Codes, Standards, STATE and <br />FEDcR,;LlawS. � 2 <br />DATE' <br />APPU0W SkMTURC a J <br />P1qoa1T1Y/Bt ssOWWM OPERATOR/MANAGER d Q+FERAUT--moaaMAQWr <br />trAPvtc.+N7i5rxtM*8j n c>saan proof of2UdW=;Wde ra sign h rmVWW rule <br />AISTHORIZATION TO RELEASE INFQRMA71ON: When applicable, I, the owner cr operarnr of the property bcamd at the above s'2e address, hereby auttwriz The relea'e <br />any and aU results, geotechnical data andlor en*anrne=Vsite a3=:rant Information to the SAN JOAOULY COUNTY PUMJC HEALTH 5swicss EMROry TAL HEALTH fl(l " as soon <br />as it is avatiaCle and at me same lime it is provided to me army repre5ermt1ve. <br />TYPE of SEFMCF. REMMsr5D: 1 <br />COMMENTS: <br />APPRovED sY: <br />ASSVMD T0: <br />Date Service Completed (f already completEA: <br />Pee Amount <br />Payment Type Invoice # <br />i:ONrRA=f' <br />PsrPeorz=� <br />Amount Paid <br />Check # <br />19ATE . <br />DA77~ <br />SERvtcsGonE '.:-:: -P I E: <br />Payment Date <br />Received 6y- <br />