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OCT -10-2012 03:37P FROM:LODI 2093342913 TO:4640138 <br />SAN joAQUyN COu1N'Tx ENVIRON1,%,NTAL HEALTU REPARTNWNT <br />RF,RVT(''TF REOUEST <br />P. 212 <br />CONTR ACTOK, I NEICkV Lk, b ALr m u r..J� x vim. <br />REQUESTbR 1 , e--CHr�xIfl�IiJAaoA_UABF ❑ <br />�dd/J&7P_-WWJJW"IVWlrX � <br />C <br />CITY <br />BILLINGA0 O'WLEDGI>✓N - .- 1, the undcnignod property or businem owner, nperatar or antharfs:ed meat of same, <br />acknowledge that all site and/or project Specific FNVIRONMENTAt, 'HEALTH DEP%►RTMiT'T heathy charges itssvciaied w4t1� this project <br />or nctivity will be billed to me or my business as Ideeutifted an tris form. <br />I also certify that 1 have prepared this application and that the work to be performed will be d(mo in accordance with all SAN JOAOl1TN <br />COUNTY Ordinance Codes, Srandart TATE find PEDERAt s. <br />APPLICANT'S SIGMA DATZ: <br />jPROMRTY I Bu. mNM 0"vnRIJ 0MRATOR I MANAGER OTnaRAvrnoxuzo AGzNT Q <br />n mrthor►ratron to sin is required r.rte <br />ljArpttcnNT is not the Btt,rtNG P�1.2rv, Proof' f <br />AU7'HORiZ�1CIOl+I '[ O RELEASE INFORL A1'>iOM: 'When applicable, i, the owner or operator of the property located at the <br />al+ove site address, hereby authorize the release of arty end all results, geotechnical data and/or cnvironmenmlAite as9c89tXfent <br />information to the SAN 7oAQVTN COUNPY EN ONM�AL �lz T" DEpARTME R5 A0� as it is available aUd at the same time it is <br />provided to amc or my rrprescntativtsa <br />TYPE OF SERVICE REOVESTEa: <br />C01AUENTS: S� - ,� f�. 3 4 W <br />ACCEPTED BY: <br />ASSIGH6D To: <br />Data Servlc* Completed Itf mlmsdy e*MPWtad?: <br />Fee Amount: Amount Paid <br />Payment 7)rpa ` Invoic-e # <br />EHO 48-02-025 <br />REVISED t 1!1712003 <br />Received Time Oct.10. 2012 4:43PM No.1358 <br />EMPLOM # <br />EMtPLOM iF <br />sPzvm coos: <br />Payment Dat® <br />check <br />DATE: <br />DATk: <br />PIE: <br />Reeelvo=By- <br />SR <br />FORM (Golden Rod) <br />