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0 <br />SAN JOA,,.) IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />CFi?Vrr� n,c�rTT�.., <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ,.� <br />BUSINESS NAME <br />A c <br />HOME Or MAILING ADDRESS <br />CITY <br />CHECK It BILLING ADDRESS 0 <br />PHONE # EXT. <br />e ) g `— <br />Lr 1 STATE ZIP <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 <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: (/1r - <br />DATE: � 4 - <br />PROPERTY / BUSINESS OWNER OPERATOR / 1VIANAGER ❑ <br />OTHER AU'1'HORlLED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 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. <br />TYPE OF SERVICE REQUESTED: L V 14 <br />COMMENTS: i <br />LIP <br />�Lz� <br />IVB L lit (`To /I - <br />ACCEPTED <br />ACCEPTED BY: <br />ASSIGNED TO: <br />Date Service Completed (if already completed): <br />Fee Amount: Amount Paid <br />Payment Type Invoice # <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />EMPLOYEE #: <br />EMPLOYEE #: <br />SERVICE CODE: <br />Payment Date <br />Check # <br />DATE: <br />------------ <br />DATE: <br />PIE: <br />Received By: <br />SR FORM (Golden Rod) <br />