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From: Franzen-Hill Inc. To: 12094683433 Page:2/4 Date:7/6/2012 10:13:42 AM <br /> SAN JOA COUNTY CouNTY ENVIRONMENTAL HEALTq&PART MXNT <br /> SERVICE REQUEST <br /> T's <br /> Type of BUSIPASS Or PrOPGOY FACILITY ID# SERVICE REQUEST# <br /> 00 <br /> OWNER I OPERATOR CHECK If <br /> ROIL"NAME <br /> M (_nL;k_NL_ okyt <br /> SfrE ADDRESS <br /> HOME or MAILING ADDRESS (If D from Site Address) <br /> OTY STATE 71P <br /> Ev. APN# LAND UsE APPLICATION <br /> PwwE#2 T BW DISTPJCT <br /> CONTRACTOR SERVICE REQUESTOR <br /> REWESTOR C HWx1fNMAJAMM[3 <br /> Bus imss NAME <br /> HOME or NWUmG AIDDRES� V 1 FAx# 6ez> <br /> ap <br /> STATE <br /> CrTy <br /> 1, the undersigned property or business owner,operator or authorized agent of same, <br /> NTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> acknowledge that all site and/or project specific ENvIRoNmc <br /> or activity will be billed to me or my business as identified on this form. <br /> I'a iso certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> Coum Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE; DATE: <br /> PROPERTY/Busomss owti=13 OPERATOR/MANAGER13 OT*im AuTHORIUD AGENT C3 <br /> If APPLICANT is not the fig&jyy PARTY proof of authorization to sign is required Title <br /> &TIAN:When applicable,1,the owner or operator of the property located at the <br /> Ammm"n <br /> above site address, hereby authorize the, release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avabble and at the same time it is <br /> provided to me or my representative. <br /> TYPE OFle ZZ <br /> SERM REWESTED. <br /> Cmwt <br /> -7 �_a� dP_k64Lc,, ct(o,f�Acsf <br /> ACCEPTED BY: EMPLOYEE 0: DATE: <br /> AsMNED TO: EMPLOYEE DATE: <br /> SERVICE CODE: PIE, <br /> Date service Completed (if already completed): <br /> Fee Amount: Amount Paid payment 11 Date <br /> 1"I"1 <br /> Check# E <br /> OICH <br /> Received By: <br /> nvoice# <br /> Payment Type Ii <br /> SIR FORM(Golden Rod) <br /> 5HD 48-02-025 <br /> REVISED 11/1712003 <br /> This fax was sent with GFI FAXmaker fax server. For more information,visit: hftp://www.gfi.com <br />