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. s 0 0 <br />'R <br />SERVICE REQUEST <br />REQUESTOR <br />BUSINESS NAME <br />MAILING MOMS <br />GUN I rua.1 VKr QrmvK Q r LwuGu- <br />c D <br />1 +ec--N n Ln i <br />BILLING PARTY ❑ <br />PHONE # <br />Rist <br />FAxg <br />3 0 <br />STATE 01 A_ ZIP <br />FJ <br />Q <br />Crrr{, _ <br />C�OZ�i ,a <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project spedit <br />PUBLIC HEALTH SERVICES ENmoNMENTAL HEALTH OMSION hourly charges associated with this proled or activity will be billed to me or my business as identified on this form <br />I also certify that I have prepared ' appliication and that the work to be performed will be done in accordance with all SAN JOAQUIN Courm Ordinance Codes, Standards, STATE and <br />FEDERALIM. <br />OATS: - <br />APPLICANT SIGNATURE: <br />PROPERTY/ BUSINESS OWNER 0 OPERATOR/ MANAGER CJ OTHERAUTEManAGENT ❑ Title <br />If APPM.Wr is nor rhe dans; Purry proof of sudwtsadon to sign is rw&W <br />RIZATION TO RELEASE INFORMATION: When appficable,1. the owner or operator of the property located at the above site address, hereby authorize the release of <br />AUTHO <br />any and R results, ATIO geotechnical data and/or errvironmental/site assessment information to the SAN JOAouw ER <br />CouNTY PusuC HEALTH SERVICES EWRONMENTAL HEALTH OMSiON as soon <br />mr1fP_SP.IH'Ative. <br />