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NOV-28-2012 17:32 From: 2098254549 To:4683433 Paset4�11 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prope L FACILITY ID# SERVICE REQUEST# <br /> X OWNS f OPERATOR <br /> nGi�cEN-�- cwt-cx;f <br /> FACILITY HAM <br /> t) t G <br /> SITE ADDRESS <br /> 7 V so-ee[Numser oo- Q.S e/b. 1 mR yv1p�� tc 7 y <br /> HOE Of ADD S (IfDiHere t from Sita Address) <br /> CITY AFA <br /> PHONE Alt APN i LAND USE APPLICATION N <br /> P110NE N1 ter. BOS DISTRICT LOCATION GOOE <br /> 1 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE4uE5TOR <br /> CNErx M BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> LS � .a�fy ft <br /> 11fr SANNG ADORES$ FAXN <br /> Cm STATE ZIp jLiz r-L, <br /> BILLING AC�A:,iVQWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HFALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this farm. <br /> I also certify that 1 have prepared this appl' ion and that the wor 11 be done in accordance with,all SAN JOAQUIN <br /> Cowry Ordinance Codes,Standar ; A and FEDERAL w\\ f <br /> APPLICANT'S SIGNA '� G �1— <br /> PROMRn/RUO <br /> STNESSwNE'k' MA <br /> OPERATOR I NAGER ❑ OTIMRAUTHORIZEnAGE. [31 <br /> !f APPLICANT is not the BILLING PARTY.proof of aathoriration to sign is required Ttrrs <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <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 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERvicE REQUESTED: I l l <br /> 'trOtBtt3tra: lam ( " �� o,� CPU a an a», o s r�'7�.A yxo'l <br /> crn.� � utsc�c 5�2.CijofLl y..� So��``�./ S�scsT l7vT , <br /> Qiv 3"'C`7 Ottr� !0�LS=�� cUE NoAtJ ollrc?rtFc AI S�`� <br /> ACCEPTED BY: EMPLOYEE P. / :-71DATE: <br /> ASSIGNED TO: _ d� EMPLOYEE#: DATE; <br /> Date Service Co Ha1ma mplated): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />