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Jan 13 15 03:02p Eli; Iv Contractors Inc 2094616'"2 <br />SAN JOAQUIN COUNTY ENVIRONMSNTAL HFALTH DEPARTMENT <br />SERVICE REO[JPST <br />p.3 <br />CONTRACTOR / SERVIC'T{ <br />HILIAN&i ACKNOWLFDGEMFNT 1, the undersigned property or busiotgs owner, operator or anthorrrcd agent of same, <br />acknowledge that all site and/or project specific ENVIRONIVIR PAL 11FALTrr DL3I'ARTMr3NT ]rvurly charges assoeiutcd 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 perfonned will be done in accordance, with all SAN JOAQIJTN <br />COUNTY Ordinance Cocks, Standards. STATE and FEDERAL laws_ <br />APPLICANT'S SIGNATURE: ) rrryry DA'L'E: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGKR U Q"r7rER AU THORIIPD ACENT� "�, w , <br />Wim.; ft <br />IJAPPUCANris not lheB1LLtKP,4RTY proof of authorization to sign it required Title <br />AUTHORIZATION TO RELFASIE INFORM.,,,TION: When applicable, t, the owner or opermtor of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMF.NT as soon as it is available and at the same time it is <br />provided to me or my repn:sentative. <br />TYPE OF SERVICE f4EQUESTED: <br />Pq Y <br />COMMENTs: <br />Se AV 7n <br />--y7� <br />ACCEPTED BY: _ EMmPLOYEE Ii: DATE: <br />ASSIGNED TO: `., L>.4`� EMPLOYEE #: DATE: <br />Date Service Completed (it already completed): SERVICE CODE: i q PIE: <br />C' <br />Fee Amount: �' Amount Paid $ Payment Daty <br />Payment Type Invoice # Chock # g / 3 I / 0 1 Received By: <br />EHa 48-02'073 5R FORM {Golden Rod) <br />REVISED 11/17/2003 <br />