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09/09/2009 WED 16: 54 FAX 209'"Q3433 SJC EHD 11001 ********************* *** FAX TX REPORT *** ********************* TRANSMISSION OK JOB NO. 2871 DESTINATION ADDRESS 94616342 PSWD/SUBADDRESS DESTINATION ID ST. TIME 09/09 16: 52 USAGE T 01' 17 PGS. 3 RESULT OK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT SERVICE REQUEST Business or Property FACILITY ID# SERVICE REQUEST# OWNAOPERATORCHECK If BILLING ADDRESSFACILrrSITE Ation /St ame it Zi Code HOME Or MAILING=SS fferent from Site Address) i Street Number Street Name CITY STATE ZIP PHONE#'I _ EXT. APN# LAND USE APPLICATION# PHONE EXT. BOS DISTRICT LOCATI N CODE ( ) CONTRACTOR/SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRES BUSINESS NAME pypy _ ExT. HOME OrMAILIN RESS 1 f FAX# / CITY . ffcy 'IUI`/1 STATE �j() uZIJP i BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, 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 th' a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standa ds,PTATE and FBDEP L ws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT p If APPLICANT is not the BILLING PARTY,proof of authorization to sign:is required Tirt e AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, 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 information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is _- proy ded.tome or_my representative. _ piq __TYPE OF SERVICE REQUESTED: Ai `C��V r COMMENTS: O aO 9 �_An.