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SANJOAQU._—'OUNTYENVIRONMENTALHEALTH,_—e.ARTMENT: SERVICE. REQUEST. Typg of Business or Properfy —' CHECK If BILLING AGGRESS D(.J $t191t11:6$ NAME I i 1 I , 1 y ' `�C _ I ePEZ 1 i /`v l.i r FACILITY ID #, : SERVICE REQUEST # 6A2F;1,0PERATQR. ''7' �L! 'nS `/- . CHECK if @IWNGADS)HE9fia4,' 'o as FAEIory NAME../ F a ) Date Service Completed (if already completed): STATE ZIP $I E.ADDR SS rd1,e. FN mD'er � ireaon root Nama STocr o,v q5"� rf . HOME or MAILINO'ADDRESS. (if Dlfferent (rola Site Addriaa) Street Number - Street a .CITY - - STATE Zip PMON' 01 fit• APN IF LAND USE APPLICATION M PNONEW t ExL .. BOB DISTRICT' LOCADON CODE CONTRACTOR / SERVICE REOUESTOR': .REQUESTOR,// I I K E: / 1 q t� l 4g —' CHECK If BILLING AGGRESS D(.J $t191t11:6$ NAME I i 1 I , 1 y ' `�C _ I ePEZ 1 i /`v l.i r EMPLOYEE A: I O�� F•q PHONE '1-11 - HOME Or M ILi ADDRESS Sr EMPLOYEE#: F a ) Date Service Completed (if already completed): STATE ZIP mo I BILLING KNOWLEDGEME T: 1, the undersigned property or business owner; operator or authorized agent of some, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have. prepared this application and that the work to be performed will be done in accordance with all SAN JoAQtRN . COuNTY Ordinance Codes, Standards, STATE a d F ERA la APPLICANT'S SIGNATURE:' . DATE: / 0s—1 o2 q P(tOPERTS/ BL'SINESS OWN ER❑ OPERATOR/M.I./GER❑ OTHERAL-THOHIZED AGENT II? Go�UrMcToK IfAPPLICA,W i5 not the BILLAG PARTY proof gf•authorization to Sign i5 required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1; the owner or operator of the property located at the above site address, hereby authorize the release. of any and all results; geotechnical data and/or, environmental/site assessment infor natlOn to the SAN JOAQurN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: CONUEMB: ACCEPTED BY: EMPLOYEE A: DATE: ASSIGNED To: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: ..Fee Amount: Amount Paid Payment Date Payment Typi Invoice # Check # Received By: EHD 4$•02-025 REVISED 11/17/2 t Received Time Aug. 10. 2012 1:04PM No, 0809 SR FORM (Golden Rod) or—