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SAN JOAQUVOUNTY ENVIRONMENTAL HEALTH D*RTMENT 2, g <br />Qiwlimrr RT.(1TTEST <br />CONTRACTOR/ SERVIUK KLgJuyalvn <br />CHECKif 0i+ ++Nd ADDRBSSC3 <br />BUSINEss NAME <br />HOME or MAIL= ADDRESS ( I w A , I i <br />FAX# <br />STATEt),r\ ZIP <br />Btt t tNG, ACKNOVnMGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPART&lENf 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 certfl q 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 Coates, Standards, STATE <br />�and <br />JFEDERAL laws. <br />DATEQ <br />APPLICANT'S SIGNATURE: W r:,/ l <br />PROPERTY/ BUSINESS owN$RI3 OPERATOR / MANAGER I' OTHER AUTHORIZED AGENT lid �1 eS <br />(f'APPL/CANT is not the BIL- W9 PARTY. proof of authorization to sign is required Tette <br />: When applicable, I, the owner or operator of the property located at the <br />above site address, heroby 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. Lt _S I 10, i9l rJ��– <br />TYPE OF SERVICE REQUESTED: �,( L <br />COMMENTS: l� 1 u Lrt> o \_ ucyr— <br />�ECEIVED <br />SEP 14 2010 <br />SAN JOAQUIN COIN <br />ACCEPTED BY: (o (� E 02 - <br />ASSIGNED TO: AI - <br />Date Service Completed (if already completed): <br />Fee Amount: 3 ( Amount Paid <br />- <br />Payment Type V \ S ilk I Invoice # <br />EHD 48-02-025 <br />(' i <br />+enzner.. _ <br />EMPLOYEE #: G3Z <br />EMPLOYEE #: n� <br />SERVICE CODE: <br />Payment Date <br />02-69 � IR <br />Nmyllm <br />DATE: g C r <br />P E: .3Ca <br />Ct 14 It0 <br />;e ved By: �- <br />SR FORM (Golden Rod) <br />