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11/10/2010 07:16 5307499892 MIDVALLEY CONSULTING PAGE 09 <br /> too <br /> SAN JOAQUIN CouNTY ENVIRONMENTAL HEALTH AR'IMENT <br /> SERVICE REQUEST <br /> FACILITY ID# eMW.F REQUEST# <br /> Type Of ++ °` (g7 `1z— 61uo f4Z4- <br /> OwttERIOPERATOR CHEF if BILLING <br /> FACIL"NAME.yt� ' •h. to � / /�./ / <br /> SttEADDRt�s/ f G l hf4t�Pr �i4ve T02t !Saar <br /> r .m <br /> HOME or MAILM ADDRESS (N otffw d tram SRa Address) <br /> S <br /> STATE ZIP <br /> Cm <br /> Exr. APIN it tAan U5�AaPucnt+ot+t <br /> PiiOiiEM '` /� �/ <br /> ( > q�T—G�2'/ LOCATION CODE <br /> Ear, HOS I WrftCT <br /> PtrM�02 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQDEMT'OR taaeca HnatjtNO ADDwE6FC� <br /> PHM# Err. <br /> RusIMIM NAM <br /> FAxt <br /> HOME or MALMO RESs { <w <br /> ZIP ZIP' <br /> Cm STATF.�'7�. <br /> Jtlld.lPlG AOgWLEDGE�T_: 1, the undersigned propnes <br /> property or business .w, operator or authorized trggAt of sans <br /> C7 <br /> aoktrowledSe that all site and%or project speoitic Exv[RON&IENTAL HEALTH IXTARTMENT hootly Charges asSOCiated With th15 Mjea <br /> or activity will be billed to we or my business as identified on this forth <br /> 1 also certify that I have prepared this application and that the Work to be performed Will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Cafes,Standards S/r/.� FF.nERAL laWS. <br /> APPLICANT'S SIGNATURE: / 1 DATE: (L��dfL` <br /> T'7 <br /> FROPM fBummssowner[3 OrESAroRlM+toAGFR 13a <br /> OTazAt^tvotDzeDAcxn� UK • c4 <br /> IU <br /> ffAPPLICANT IS thhe DILLINGPARpmufofsu*Oy7adm losign is reguhed rUk <br /> AtORIZATION TO RELEASE INFORMATION:Whe <br /> rrstn applicable,1,the owner or operator of the prvpeHy located at the <br /> above site address, hereby authorize the release Of any and all results, geowarnicId data andf'or environmentalisite assessment <br /> information to the SAN JOAQUIN COUNTY E7rvme(R ENTAL HEALTH DEPARTWNT as soon as it is available and at the same time it is <br /> provided to me or my repwAntative. <br /> TYPE OF SEWICE REQUESTED: 'tY <br /> CONIAMM <br /> AcCrEarTWDV' r EMPLoYEE9- '4J � DATE <br /> Ass oraID To: ca EMPLOYEE O: (F DATE: <br /> Date Service Comptetnd (if akeedy conoNTodf: 6CQOE: �'!`6 P/E <br /> Fee Amount B? Am t Paid Payment Date 1 0 v <br /> Payment Type If �InvWCe0IO� OCrhelck# <br /> E7R ivSsRdFORM <br /> EHD <br /> (GddEn Rod) <br /> REVID�712W3 it / /v <br />