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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVIU L KWUEZ5Iun <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT 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 FEDERAL la <br />APPLICANT'S SIGNATURE: DATE:/Y <br />PROPERTY I BUSINESS OWNER ❑ RATOR I MANAGER ❑ O-rHF-kAuMWW G ✓*' <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tp Title h <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It is provided t0 me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: <br />ASSIGNED TO: <br />Date Service Completed (if already completed): <br />Fee Amount: Amount Paid <br />Payment Type I Invoice # <br />APR 3 0 2014 <br />ENVIRONMENTAL <br />S <br />OYEE #: 7DATE:OYEE M <br />SERVICE CODE:PIE: <br />Payment Date <br />Check # <br />Received By: <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />07/17108 <br />