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1 <br />Type of Business or Property <br />F`r <br />COMEWS. <br />Vol <br />CHECK if ... <br />SERVICE�� <br />EMPLO : <br />DATE: <br />- AssmwTw. <br />i <br />.. <br />HOMEi #. <br />�: <br />i. <br />Date ice Completed{i6 a344 <br />c d): <br />r <br />CITY <br />�llrwam- <br />STATEA: <br />r <br />PaymentDate <br />oice># <br />check#tI <br />Received <br />HOME or Ati" Offte from Ske Address) <br />Strf" Number <br />CITY <br />STATE zip <br />Z <br />LAND USE APPUCA-noti�I <br />LocAMON CODE <br />CONTRACTOR I SERVICE REOUESTOR <br />REouESTOR <br />F`r <br />COMEWS. <br />Vol <br />CHECK if ... <br />BUSINESS NAME <br />EMPLO : <br />DATE: <br />- AssmwTw. <br />.. <br />HOMEi #. <br />�: <br />i. <br />Date ice Completed{i6 a344 <br />c d): <br />r <br />CITY <br />rue if. t(tYt: <br />STATEA: <br />r <br />ING ACKNOWLEDGEMENT- 1, the undersigned property orXnsiness owner,%operator or authorized agent of setae, <br />acknowledge that all site and/or project specific ENVLRONMENTAL HEAVrH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this ford. <br />I'also certify that l have prepared this application and that the worljrto be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws,' <br />APPLICANT'S SIGNATURE, DATE: <br />PROPERTY / BusiNEss OWNER® OPERATOR / MANAGER'0 OTHER AuTkmaizEyD AGENT <br />If APPtreAw is not the BgLiNG PARTLY proof of autho4z[adon to sign is required Title <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 o,f any and all results, geoteehnical, data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY;ENvIRONvLENTAL HEALTH DEPARTMENT as soon as it available and at the same time it is <br />provided to me or my representative. <br />T OF cE E <br />F`r <br />COMEWS. <br />ri <br />t <br />A Dv: <br />EMPLO : <br />DATE: <br />- AssmwTw. <br />EMPLOYEE 5: <br />DATA <br />Date ice Completed{i6 a344 <br />c d): <br />CME. <br />P i E: <br />rue if. t(tYt: <br />AmountPaid <br />PaymentDate <br />oice># <br />check#tI <br />Received <br />Payment Type T�v <br />END 48-02-025 <br />REVISED 11/1712003 <br />SR FORM (Golden Rod) <br />