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06/27/2001 13:57 <br />2094133 <br />FIFTH FLOOR • <br />SERV E REQUEM <br />CONTRACTORISERVICE REOUESTOR <br />-•c <br />81LLING ACKNOWLEDGEMENT: G the undersigned property or business owner. optxator or auth dwd agent of same. adutawiec: a teat ail srra arwor project speanc <br />PUauC HEALTH SERVICES Errvir�NNt7tiAl HEALTti omsioN hourly ctwrges associated w4b thrs prnjec3 aracuvdy wilt be billed to ma or my business as idenizr ed an '.orm- <br />I also certify that 1 have p.•epvL%d this app tion and that Cie work to be perfouned will be done in acxrdance with all SAN JCAOuIN CWNN 01dinz= codes, Staf4atd,' SATE and <br />FomAL Laws, K—"\, 2=0TKRAUTw)F=AC-z_W Q 3 <br />—/" o <br />APPUCAxr SRWATURE aimOATS' <br />R- <br />Feoa rrl8usrr sS Ovrr z a OPERATOR MMAGER 0 ritro <br />audwri;Q i to sign k rrquvad <br />AUTHORIZATION TO R>=L£ASF IN/oRMAT10N: Men applicable, 1, the Omer or operatnr of the propetty io=d e, tie above site address, hereby auitMiM the release of <br />any and aU results, geotechnical data arxllor enviranmenwilsite assessrmat information to the SAN JMQUW COUNTY Pl>Buc HE.;LTH SERvrcFs ErMROra SAL HEAL—'4 C( a" as soon <br />as 4 is evadable and at the sane trine itis provided to me army represernafiw- <br />TYPE OF St sv10E REotmyrw: <br />�vz G • ✓� . C�� 01V Boa <br />GU>�rc.� �`� �-la�T��� ��ri>ztcsar��✓ � _,,,NTY <br />(� •3VISIOfT <br />, <br />APPROVED BY: ( �.i C <br />A$Sin=To- <br />Date Service Completed (if already comPieted): <br />Fee Amount 0 1/- r7 C% G <br />Payment Type i% I invoice# <br />CoNrRA=FeS SrWTURE: <br />EMPLoYi=1: x I DAT-- 6 /,S— D <br />SE zv1cE Cone t . ; -PIE - 3 �% <br />Amount Paid 26 700 ` Payment Date 67- - 03 <br />Check # 4 R_-CeNed Ey: <br />