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SAN ,IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTAIENT <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR <br />Watttiesa NAME <br />HOa1E or <br />FAta <br />I crr.n- „ L . Surd zip n z-. ^u <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or suthoriztd it" of saltie, <br />acknowledge that all site and/or project specific ENVIRONMI:KrAI. I II:A1.1 n DtteARTMu i hourly charges associated wrth thn pmlat <br />or activity will be billed to me or my business as identified on this film. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all Sh%InAmr.4 <br />Cowry Ordinance Colles, Standa STAW and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ) 1 /��/pJZ V U.1�T DATE:S hp <br />MA. <br />PROn'/BuslN'ec+0u�rs 01'rRATOR/AIANACERD OrnutAtmwRtn7tArtN-rC1 <br />IfAPPl.1G1AT 1r nor the B/1j,1,VG PARTY. Proof of adthariaiNan to sign is requirted Tigre <br />A1177IORIZATION TO RELEASE INFORMATION: When applicable, 1. 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 andlor cnvimrtmental/site assessment <br />infoR"mWit to the SAN 1OAQUIN COUNT' ENVIRONMEA'TAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to ilre or my representative D ` <br />-. IlT <br />TYPE OF SERVICE <br />ACCEPTED Sr. <br />ASSIOMED TO: V I V t V r <br />DS% S01v(CO CoTplttlod (If dready CtYMMb(1): <br />- l „r"i - ft O AltmuM <br />EMPLOYEE* <br />tm fent tr Check f <br />TMPD /S'o--- <br />MAY 2 0 2020 <br />8ANJOASAL IRONMEN7A(NrY <br />H DEPARTMENT <br />sortu¢ Ca W /)l <br />DATE <br />DATE <br />SRfORM (Golden <br />