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REQUES7OR <br />SELLING ACKNOWLEDGEMENT: !, the undersigned property or business owner, operator or' authorized ,agent <br />ADDRESS <br />Emily Crain <br />CHECK If B)f.UNG <br />BUSINESS NAME <br />PH04E# EXT' <br />BZ Maintenance <br />�. {'.sS1GIN EO Y0: V1 i',.�_ ; r� .',r <br />916 371-2380 <br />HomE Or MAILING ADDRESS <br />Golden <br />FAxft <br />PO Box 933 <br />( ) <br />CITY W Sacramento <br />STATE CA ZIP 95691 <br />of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH,DEPARTMaNT hourly charges associated with this project or <br />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 performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />w7 APPLICANT'$ SIGNATURE: �r ��,�� t 1�6 DATE : �.t L <br />PROPERTY (BUSINESS OWNER 13 OPERATOR/ MANAGER OTHER AUTHORIZED AGENT ❑ <br />I - If APPL CANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and, all results, geotechnical data andlor environmentallsite assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTtAENT as Soon as it is available and at the same time it is provided t0 me or <br />my representative, PAYMENT <br />q pro" <br />TYPE OF SERVICE ReWESTED: f�� f <br />GOiitdENrTS: , _ 8 021 <br />!.: _.... SAN JOAQUINCOU TY <br />!( ENVIRONtA CNTA <br />1 UEALTIIOrl'All"' NI <br />} I <br />,SGL'EPTEr� ,,�,Q� EMPLOYEE i$: <br />DA <br />I <br />SR FORM ( <br />�. {'.sS1GIN EO Y0: V1 i',.�_ ; r� .',r <br />EMPLOYEE #: <br />DATE: <br />Golden <br />Rap) <br />{ rr.,,rra Se. vies Completed (if a31ready comploted):. <br />F Amoun': � c� <br />f�moLlnt Paid �- <br />Payment Date <br />Y <br />n rant-+ Jf3e 11 invoice # <br />Check # Received By: <br />Golden <br />Rap) <br />