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10/05/2006 10:12 FAX 7148250685 Clayton_GrpLA <br /> 0 aw <br /> r SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S2 0 0 (8 <br /> OWNER/OPERATOR a64-L CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS J2_I1' --4� C. pyyd I� <br /> Street Number Direction e Name city <br /> HOME or MAILING ADDRESS (If Different from Site Address) P\V tq V1� <br /> Sfreet Number ) S reet Name <br /> CITY STATE ZIP <br /> ct <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> Cl <br /> PHONE#2 EXT. SOS DISTRICT LOCATION COQE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR ? j�✓�/^ ! t. CHECK If BILLING ADDRESS <br /> BUSINESS NAME C i PHONE# EXT' <br /> e,w,�' 1A C-1 , Se cn( �-�- --L-1«2 <br /> HomEorMAILINGADDRE FAX# <br /> 15Qk (-+HDV 10d cel ) v2S -too <br /> CITY rI STATE !"�� zip 9 Zb Z <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTEI DEPARTMENT hourly charges associated with this project <br /> or 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 accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE-a L laws. <br /> APPLICANT'S sIGNATCIIZE: DATE: <br /> PROPERTY/$USINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTA 02 L11L <br /> !f APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,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 ENVIRONMENTAi.HF..ACCH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. yy <br /> TYPE OF SERVICE REQUESTED: Z 1,:1 <br /> COMMENTS: t�GJ GnS (� ,`1i r�C{��1 CEIIE� <br /> OCT - b 2006 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: EMPLOYEE##: LTH W <br /> C <br /> ASSIGNED TO: /" V� EMPLOYEE#: DATE: lo 4- <br /> Date Service Completed (if already completed): SERVICE CODE: 3�0 P I E: () <br /> Fee Amount: Amount Paid S ,6D Payment Date V( �.16-6 <br /> Payment Type ✓ Invoice# Check# a36LA Received 6y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />