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--- c -•• -•���•+a -v11riiNvtIITAI1N1HL1JLJrA-U1t "IWA1C11N1ENI' <br /> SERVO, F EQUEST• <br /> Tyne of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -7-7 <br /> 01NNER/OPERATOR <br /> CHECK if BILLING ADDRESS D <br /> FACILfTY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name <br /> CityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Ad ess) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> i <br /> PHONE#1 ExT APN# <br /> LAND USE APPLICATION# <br /> PHONE#TT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUEST <br /> j CHECK if BILLING ADDRESS El <br /> BUSINESS NAME 1. P N J_�f <br /> HOME Or MAILING ADDRESS.��� �\ t -\= ( ��� <br /> CI7y 1 ld STATE (� ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> :activity will be billed.to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDlaws: <br /> APPLICANT'S SIGNATiTRE; -DATE: <br /> C`� 1 <br /> P1tOPERTY/BUSINESS OwNERL] OPERATOR/MANAGER 0. AvTnoRrzED AGENT <br /> fAPPLICANT is not the BILLING PARTY proof of authorization to sign is require Tire <br /> --- -.- - <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property located at the <br /> above.site address,.hereby authorize.the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> lnformafion to the.SAN 70AQu>rI COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or w representative. <br /> TYPE OF SERVICE REQUESTED: <br /> PAYMENT <br /> toal►r>FXrs: R En G En <br /> AUG 2 6 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: iu <br /> EMPLOYEE#: Q DATE: <br /> 3 - <br /> ASSIGNEDTO EMPLOYEE#; ? DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: f �' P t E: <br /> FeeAmount: Amount Paid ) �. Payment Date $ 2 <br /> Payment;Type invoice# Check# L( y - JoReceived By. <br /> tEVIS 11117120031 C 3. S <br /> D <br />