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1 <br /> r± <br /> �r <br /> C I T `t pr 3 u11 <br /> ai <br /> BILLING ACKNOWLEDGEhiENTI j,, � lilxlerslgritd owner,' operator' or`agent of Am*, ackh6wl6dg4 that att'Mt$ and/or project specific . <br /> OHSIM hourly charges Assoc f'a ed with this facility or activity will ba bitted to 66 Oe ty identified at the BILLING PARTY on <br /> Paas i o1 this forta, <br /> a <br /> I'also certify that I have prepared this application and that the work to be perforated mill be done in accordance with all SAN <br /> CUIN COUNTY Ordinance Codes and Standards, State 9nd Federal lows, <br /> Y <br /> ,'APPLICANT'S SIGNATURE <br /> Hite: pate: <br /> AUTHORIZATION TO RELEASE INFORMATION! In addition to the above, whtn applicable, I, the owner, opeh6t6r Of, tyleht of aw*, of <br /> he Oroperty located at the above site Address hereby authorize the release of any and all`resutt6, 06ottAhI661,'data and/or 5 <br /> envirotmental/sitO assessmeft tMormatioh to SAN JOAdUIN tOUNt'Y PUBLIC HEALTH SERVICES ENVIRollkNTAL 1100&DIVI916,4 oon as <br /> `It is availabte and at the semi tih>t it 16 provided to'Me or my reprtaentitive. <br /> 1 Nature of Service Recrieat (ii'i l:ervlca C <br /> Assigned to �(, �J/il 445 Employer If _ }� bbte :/ �/� <br />�,+ ,i <br /> ` <br /> Date §ervlce Completed I I Further Action Requlred: Y / m3d!1L IENT .3d! <br /> fee Amount Amount Paid bate of Payment Peyment Typo Reefllpt N Check N Recvd By <br /> P <br /> 1 <br /> Ogg` /e� �a �� g � 151 <br /> .,- ES / <br /> _L_/ I SUPV _/_/ ACCT `/ J UNIT CLK <br />