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3 <br />ecolnrt: RCr1lIFi7 <br />Type of Business or Property <br />FACILffY ID # <br />SERVICE REQUEST # <br />COMMENTS: <br />REOUESTOR <br />r�j <br />BILLING PARTY ❑ <br />OWNER I OPERATOR <br />PHONE# EXT <br />BUSINESS NAME 7 <br />FACILITY NAME <br />< <br />,1 <br />SAN JOAQUIN COUNTY <br />C <br />PUBLIC HEALTH SERVICES <br />SRE ADDRESS I 3 �> C-) le <br />. I Yo S P M, lk <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />C TY r — r r ^ STATE ZIP .J <br />Suaat Number Diroctien Sheat Naim <br />APPROVED BY: <br />T <br />Surat <br />PUBuc HEALTH SERVICEs ENVIRCNMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br />ASSIGNED T0: <br />Mailing Address (If Different from Site Address) <br />DATE <br />—1E: <br />FEDERAL laws. <br />DATE: <br />��, AAPPLICANT <br />1 <br />CITY <br />SERVICE CODE: `7 0 <br />STATE ZIP �l / <br />Fee Amount: <br />,. <br />PROPERtt I BUSINESS OWNER C OPERATOR / MANAGER ClOTHER AUTHORIZED AGENT M: <br />pal cf su&w=don to sign is rwWWW Title <br />UAPPLCAMr is nor Cie 6UftC P,wrvro <br />EIT• <br />APN # <br />LAND USE APPLICATION# <br />a. <br />of <br />any and all results, geotechnical data and/or environmentallsde assessment information to the SAN JDAouLN COUNTY Pusuc HEALTH SERVICES ENVIRONMENTAL HEAL�I DMSION as soon <br />PHONE #1 EXT. <br />f <br />I BOS DISTRICT <br />LOCATION CODE <br />TYPE OF SERVICE REQUESTED: <br />LUft 1 KA;- 1 UK I OCI[n\.c IaLVWQ r— ,,.,./ <br />BIwNG PARTYE <br />COMMENTS: <br />REOUESTOR <br />r�j <br />PAYMENT <br />PHONE# EXT <br />BUSINESS NAME 7 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />MAILING ADDR/E/SS�y� FAX # <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />C TY r — r r ^ STATE ZIP .J <br />11'V <br />APPROVED BY: <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specfc <br />EIIPL': Ymff: '1„ �L <br />PUBuc HEALTH SERVICEs ENVIRCNMENTAL HEALTH DIVISION hourly charges associated with this project or activity will be billed to me or my business as identified on this form. <br />ASSIGNED T0: <br />1 also certify that t have prepared this appficaGon and *hat the work m be performed will be done in acmrttance with all SAN JOAGtnN COUNTY Ordinance Codes, Standards, STATE and <br />DATE <br />—1E: <br />FEDERAL laws. <br />DATE: <br />��, AAPPLICANT <br />1 <br />SERVICE CODE: `7 0 <br />��.� �. <br />SIGNATURE' _ <br />Fee Amount: <br />,. <br />PROPERtt I BUSINESS OWNER C OPERATOR / MANAGER ClOTHER AUTHORIZED AGENT M: <br />pal cf su&w=don to sign is rwWWW Title <br />UAPPLCAMr is nor Cie 6UftC P,wrvro <br />Payment TypeInvoice <br />i <br />° <br />. <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 <br />a. <br />of <br />any and all results, geotechnical data and/or environmentallsde assessment information to the SAN JDAouLN COUNTY Pusuc HEALTH SERVICES ENVIRONMENTAL HEAL�I DMSION as soon <br />,s <br />.,.. ;I K —aihln —t it NIP ca (MIP- it is nrovlded to me or my reuresentatrve. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />PAYMENT <br />RECEIVED <br />MAY 2 2003 <br />SAN JOAQUIN COUNTY <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />INSPECTOR'S SIGNATURE: <br />CONTRACTOR'S SIGNATURE: <br />APPROVED BY: <br />EIIPL': Ymff: '1„ �L <br />DA'M' <br />ASSIGNED T0: <br />EMPLOYEE #: /' <br />DATE <br />—1E: <br />Date Service Compl (if already completed): <br />SERVICE CODE: `7 0 <br />P L b <br />Fee Amount: <br />I Amount Paid 7 , ©D <br />Payment Date <br />Payment TypeInvoice <br /># <br />Check # <br />ri :i—.,•,ni,1 II r it <br />MAY 0 2 2003 <br />PERMIT/SERVICES <br />