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�� crov�rr n <br />Type of Business or Property O <br />F FACILITY ID # _ <br />SERVICE REQUEST # <br />P N_E # Ext. <br />MAILING ADDRESS <br />OWNER/ OPERATOR <br />co�(M) <br />CITY <br />, STATE ZIp <br />BILLING PARTY <br />CC 0 <br />FACILITY NAME 1 1( <br />SITEADDRESS <br />&—Zr <br />/ <br />StrtetNumber Direction <br />Mailing Address (If Different from Site Address)PC&Y, <br />SVMNam� <br />TYPO su"I9 <br />� �U J�- <br />CITY ' <br />2161 <br />STATE %p <br />PHONE #'1 <br />( <br />ExT• <br />A N # <br />LAND USE APPLICATION # <br />PHO E3 ` 03 <br />EXT.BOS <br />DISTRICT <br />LOCATION CODE: <br />R.�evean..r��.��:�•nwa:���iusyuvi <br />REQUESTOR BILLING PARTY <br />C <br />BUSINESS NAME- / <br />P N_E # Ext. <br />MAILING ADDRESS <br />CITY <br />, STATE ZIp <br />bILLINU AUKNUWLEUGEMENT: 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 />I also certity that I have prepared this applicab and tha the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. O <br />APPLICANT SIGNATURE: <br />DATE: <br />PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT <br />Il Apar—wr is not the euM Pam: proof of aulhoruatlon to sign thsrauquimiK 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 environmental/site assessment information to the SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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: US <br />COMMENTS: <br />INSPECTOR'S SIGNATURE: <br />APPROVED BY:. /\; <br />ASSIGNED TO: <br />Date Service Completed (if already completed) <br />Fee Amount: <br />Payment Type <br />Invoice #' <br />SpUB�o N00NEP�Sri O�V�S�ON <br />ENVIRONMENT P� <br />CONTRACTOR'S SIGNATURE: <br />EMPLOYEE #: 7 Q ^ DATE: <br />EMPLOYEE#: J DATE: 6 _ t_ ✓ ©J 3 <br />J SERVICE CODE: O� Jj <br />"l U P/E:. �:.3Q�i. <br />Amount Paid �t� ` Payment Date <br />Check 9 ��� S I Received By: 2� <br />rim <br />