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n SFRVTCF RFdUFST Type of Business or Property FACILITY ID # SERVICE REQUEST # :1� r '0 L t REQUESTOR CONTRACTOR'S SIGNATURE: BILLING PARTY 0 OWNER I OPERATOR 'l i IL BUSINESS NAME A L� C I+C Urit��rAL( C _ PHONE # 916 3 *- - FACILITY NAAE ! q v I IL 5 T-0 MAILING ADDRESS 0. 0 O ZS SITE ADDRESS 1.W - O C le I�C)yx ST OD 1 suiu � Sunt Numbv 2-01.6. Payment Payment Type Strnt Name r TYPS Received By: Mailing Address (If Different from Site Address) ��Ii_ CITY tt �iM 0 t ii}� r STATE C ZIP PHONE #1 �• APN # LAND USE APPLICATION # PHONE #2 err. BOS DISTRICT LOCATION CODE BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge That all site and/or project spec= PUBLIC HEALTH SERVICES ENVIRGWAENTAL HEALTH DIVISION hourty charges associated with this project or activity will be bided to me or my business as identified on this form. I also certify that I have prepared this applicalln and that the work to be perfa will be done in accordance with all SAN JOAOUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. YUA O Z' APPLICANT SIGNATURE: OATS PROPERrY / BUSINESS OWNER CI OPERATOR Y MANAGER OTHER Auniommo AGENT ifAPvurwisncYtloSLLmc rn proof 01sudmrfzatbntosip is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and ad results, geotechnical data andfor environmentallsite assessment information to the SAN JOAOUIN COUNTY Pueuc HEALTH SERVICES ENVIRONWNTAL HEALTH DmsION as soon __.. - — .,—. x,.,e a is —id -4 M mn or rm renrasentative. TYPE OF SERVICE REQUESTED: u&7— BILLING PARTY REQUESTOR CONTRACTOR'S SIGNATURE: ' C a Art"— EIIPLLYa# BUSINESS NAME A L� C I+C Urit��rAL( C _ PHONE # 916 3 *- - EV. 1 MAILING ADDRESS 0. 0 O ZS Date Service Completed (if alrea completed): FAX # 'C SERVICECoDE: /.� CITY A—t I) tx w- r v --OK V STATE C A S 6 R BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge That all site and/or project spec= PUBLIC HEALTH SERVICES ENVIRGWAENTAL HEALTH DIVISION hourty charges associated with this project or activity will be bided to me or my business as identified on this form. I also certify that I have prepared this applicalln and that the work to be perfa will be done in accordance with all SAN JOAOUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. YUA O Z' APPLICANT SIGNATURE: OATS PROPERrY / BUSINESS OWNER CI OPERATOR Y MANAGER OTHER Auniommo AGENT ifAPvurwisncYtloSLLmc rn proof 01sudmrfzatbntosip is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and ad results, geotechnical data andfor environmentallsite assessment information to the SAN JOAOUIN COUNTY Pueuc HEALTH SERVICES ENVIRONWNTAL HEALTH DmsION as soon __.. - — .,—. x,.,e a is —id -4 M mn or rm renrasentative. TYPE OF SERVICE REQUESTED: u&7— COMMENTS: INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: APPROVED BY: EIIPLLYa# DATE'' ASSIGNED T0: ' V yt � EMPLOYEE #: S3 `yL DATE: Date Service Completed (if alrea completed): SERVICECoDE: /.� PIE: �3 Fee Amount: j` C r� Amount Paid % 0--o Payment Date -L — 2— Payment Payment Type Invoice # Check # Received By: