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'Feb 12 14 09:41a Elitr 'V Contactors 1209461 '42 p.2 <br />SAN JOAQUIN COUNTY <br />Type of Buslness or Property <br />OWNER I OPERATOR <br />ti+.. .. . . <br />RO NTAL HEALT El DEPARTMEN 11. C P YOf REQUESTT <br />FACILITY ID # : .SERVICE REQUEST # <br />FACILITY NAME �' i ;!•.1'��I�, 4i } (t. C 1^ + <br />SITE ADDRESS l3,y5 : <br />Street Number Direction Street Name <br />HOME or MAKING ADDRESS (if Different from Site Address) <br />CITY <br />RHONE #4 ExT• APN # <br />PHONE #Z EXT. <br />( ) <br />CONTRACTOR/ SERVICE RE( <br />REQUESTOR <br />CHECK if SiLLING ADDRESS <br />City Zio Code <br />STA TI — -Zip <br />LAPID . SE APPLICATION # <br />13013 1STRICT b <br />IUE 3TOR <br />LOCATION CODE <br />/ter /' r <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME I t: t , PHONE# <br />i— I' r a j� /�i`i'��If it ;17� <br />;ii Iir — <br />HoME or MAILINGADDRI;SS Fax# <br />j. <br />` ST. k1 ZIP <br />� .; 1'y <br />CITY . <br />_ R% �.�•� <br />BILLING ACKNOWLEDGENIENT: I, the undersigned property or business ow:ue , operator or authorized agent of sante, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMEN' 1 :surly 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 wi: l e done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: } "; `. ,,.: rt. _ DATE:, <br />PROPERTY IBUSINESS OwNER❑ OPERATOR I MANAGER El OTHER AUTHORIZE') .GENT3s1 <br />If APPLICANT is not theBILLING PAR TY, proof of authorization to sign is re wired Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owr.e or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechni:-a data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as s. 0, it as it is available and at the same tune it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: ` a� <br />COMMENTS: PAYMENT <br />RECEIVED <br />FEB 1 r,�fa. JAN 8 12014 <br />o�a�anrYiiiYYl�l�t\TAY SANJOAQUIN_COUNT.Y <br />ACCEPTED BY: era- &t <br />ASSIGNEDTO: 'jZ L,-5 <br />Date Service Completed (if already completed): <br />Fee Amount: �, ' � Amount Fald <br />Payment Type j Invoice # <br />EMPLOYEE #: DATE: <br />SERVICI: :)DE: l ' PIE: <br />Payment Date L 0 { <br />_. <br />heck # •� �' ' I Deceived By:. <br />cum AO no noG SR FORM (Golden Rod) <br />