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a" <br />crovinc n Ak <br />Type of Business or Property <br />GIF <br />FACILITY ID # <br />t --A- <br />'SERVIC E REQUEST # <br />04e�37q� <br />�� GC �YO3.1-- <br />OWNER! OPERATOR <br />BILLING PAR <br />FACILITY NAME 71.E <br />SREADDRESS000 Strut Numbor Direction <br />�...• <br />/ / / ( / C� Name <br />Mailing Address (If Different from Site Address) /10 <br />�� �_�� �� <br />TYPE sub I <br />CITY <br />STATE/),? ZIP <br />PHONE #1T• <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PH E 2 EST. <br />POS DISTWCT <br />LOCATION CODE' <br />REQUESTOR <br />BILLING PARTY <br />BUSINESS NAME /J <br />PHONE # Fxt• <br />b <br />MAILING ADDRESS �j//� F <br />CITY <br />STATE Zp <br />DILLINU AL F%NUWLtU1JEMtNT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific <br />PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br />also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAOUIN COUNTY Ordinance Codes, Standards, STATE and <br />also <br />laws. <br />APPLICANT SIGNATURE: S LDATE: v <br />PROPERTY/BUSINESS OWNER O OPERATOR/ MANAGER 11 OTHER AUTHORIZED AGENT <br />IIf APPLc wr is not the Bum pnrtry proor of authorization to sign is requiJ. Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of <br />any and all results, geotechnical data and/or environmentaVSite assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DrvISION 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: j� /1 <br />Il " ` ✓ 1'r/4 G Fl r <br />COMMENTS <br />INSPECTORS SIG <br />APPROVED BY:. <br />ASSIGNED TO: K- V& . ae v <br />bate Service Completed (if already completed): <br />Fee Amount: f� 04, <br />Payment Type I Invoice # <br />CONTRACTORS SIGNATURE: <br />EMPLOYEE#: Z Z Ca_ a <br />T <br />UTV, <br />,� GOUNjV <br />N J'Pa ��NSERV\p\V\S10t1 <br />?kg&2 ZP\-HEP\SN <br />ENV\RAN <br />DATE: <br />EMPLOYEE #: �t DATE: 6 D <br />SERVICE CODE: P 1 E:, <br />Amount Paid of <br />Check # <br />r <br />Payment Date 0�- CJS _per <br />CI Received By: 1 <br />