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M, <br />s • 0 <br />SFRVICE REQUEST <br />GC1N 1 KAG 1 UK i OCKYR C K -%AUQp 1— <br />BILiJNG P <br />REQUE TOR <br />C <br />MAILING ADDRESS l / n F x # / ge-0 <br />/ A STATE LP <br />BILLING ACKNOWLEDGEMENT: 1, 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 OmsiON hourly Charges associated With this project or activity will be billed tome or my business as identified on this form. <br />1 also certify that I have prepared this application and th a work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and <br />FEDERAL laws. <br />APPLICANT SIGNATURE: s DATE: (l <br />/��., �/ <br />PROPERTY/ BUSINESS OWNER Q OPERATOR/MANAGER Vie OTHER RQEDAGENi !Q �� Title <br />If ApR carr is not Bt! 2 P—AM proof of ae d-- � �s WIj <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located atthe above site address, hereby authorize the release of <br />any and all results, geotechnical data andfor errvironmentallsite assessment information to the SAN JOAOUW 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: <br />COMMENTS: �tms- <br />ccs Es <br />'pPpV�N SEp,V\CN\S\U� <br />SPN \cNEP\'NEP\�N <br />pU8`MENZ P� <br />ENV\F�U� <br />APPROVED BY: Eapl-ayat Z.'Z a% .Z DATE-* <br />ASSIGNED T0: EMPLOYEE #: J ? DATE: —1(0 ` O j <br />Date Service Comp (if airea completed): SERVICE CODE: ,p P / E. �� <br />6 <br />Fee Amount Z;D Amount Paid 4';L(.E-7j Payment DatePaymentType / Invoice# heck# l3?S Received By: Z,,j� <br />