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<. <br /> In�ss ArProperty <=ACiLITY1D :. SEkW12:RERU ST` <br /> nn <br /> CHECK If BILLING ADDRESSU <br /> {F/1CILITY NAME <br /> /Vq 7`e.-is/ c a �-. 4,— �a � <br /> -SITE ADDqSSR, <br /> ,,StreetNumber. Direction -,C .- Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> StreetNumber Street Name <br /> CITY STATE ZIP <br /> PHONE II APN=# LAND OSE APPLICATION# <br /> l ( ? <br /> ` <br /> PHONE $ ExT• BOS DISTRICT LOCATION CODE <br /> _T <br /> CONTRACTOR/ SERVICE REQV�ISTOR <br /> REQUESTOR <br /> CHECK if BILLING MDRESS <br /> / BUSINESS NAME <br /> HOME or MARAM ADDRESS Fax# <br /> \ CITY f C{C` 97 STATE <br /> TRILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> a'knowledge that all site and/or project specific ENmotimwTAL HgALTuDEPARTty mi r hourly 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 will be done in accetdance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL lalm. <br /> APPLICANT'S SIGNATURE DATE: ! ` <br /> PROPERTY/BUSINESS OWNER OPF.RATORI IVIANACER=CJ OTHER AUTHORIZED AGENT <br /> YAPPUcA f is not the BILLING PARTY.proof ojautha `xri;bK to sign is required T/!ia <br /> 4U'1'IOItI7ATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property locatedtit the <br /> above site address,-hereby authorize the felease 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 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERYICE.REQUESTED: fy( r°t .lYl C ry <br /> CONVENTS. <br /> ACCEPTED BY: - o EMPLOYEE#.-. IeOJ f DATE:,/1.A9 <br /> ASSIGNED TO �'p �/ �— EMPLOYEE# �d Z/ DATE: <br /> Date Service Completed (if already complet d): SERVICE CODE: 2� P 1 ElZ <br /> Fee Amount: #'t .S Amount Paid Payment Date <br /> Payment Type v/ <br /> Invoice# Check# R ceved y: <br /> EHD'48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />