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I-VTTr I-) <br />SAN JOAQ COUNTY FNVM Ni►+IEi: NAL REAL, CPARTMENT <br />SERVICE RI+ 01 FqT <br />'UHN'rHACTQIt / SERVICE REQUESTOR. <br />REikIJESTpR <br />HOME or MAIuNG ADDREss <br />Cm <br />NONE # <br />FAX# <br />STATE 'ZP <br />I3 1.7MIs'► AC ULO—WLEDGEMENT: I, the undersigned property Or business owner, o <br />Aerator or sutllorized agent of same, <br />acknowledge that all site and/or project specii'ie ENVIRONMENTAL HEALTH DEPARTAIENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 also cm'* that I have prepared this application and that the worm to be perfortned will be dans in accordance wvitj all SAN JOAQUIN <br />COCNff 0119"a"ce COdksr, Standanuk STATE and)FEDERAL laws. <br />APPI,7iCANT'SSIGNATUR£: <br />DAT9: <br />)PROPER Y' / BUSMSS OwNM ❑ OwRkATOR /MANAGER ❑ OTEwR AuTHOWUD AGI&NT ❑ <br />,MFPLIC.4NT is'Prot the &L1NC PaRTy, Pmofof aNJ*0rizglon to sign is requ&ed Title <br />AMLY10 t. ,AD -IM TO R LSE NF''U.gg&TON: When applicable, I, the owner or operator of the prop" located at the <br />above site address, hffcby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />infOrmatio[t to the SAN 1UAQUIN COUNTY ENVIPO'NUENTAL HEALTH MPART'MENT as goon as it is available � <br />provided to me or my representative, �/ ' � w _ ��rtji- <br />TYPE OF SERVKE IiWESTED: <br />COMMENTS: <br />AccEpTsoBy; <br />ASS1Q1dEv T+o: Kµ � J <br />Date Servloe Completed (if aim COmplated): <br />Foo Amowt: D Amount <br />Payment Typevi` Invoice # <br />EENVAIRONME <br />EMPLOYUE M DATE: <br />EMKOYEE OF DATE: <br />SERVO Cone icl <br />'3 b. a v Payment Date 3 c <br />It Re" <br />PIE: <br />�a By: 4 <br />EHD 45-02.026 <br />REVISED 11117/2 0M SR FORM (Golden R* <br />r <br />A! <br />1T <br />