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06/17/2005 08:30 20946834" EHD PAGE 02 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMYNT <br />SERVICE REOUEST <br />UK <br />CONTRACTOR / SERVICE REQUESTOR <br />PHONE 9 <br />CHECK If &WNA AOD wp <br />Howior Mm m p A DREM - - � FAX C <br />Cry , /-1I✓ A�. ��!t' /� STATE ( �tP 93cyd <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 HEAL'T'H DEPAKtMENT 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 ctr ify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUrN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Aov DATE:�� -CS <br />PROPERTY/BUSINESS OWNER 13 OP TOR/MANAGER ❑ OTHERAUTHORIZEDAoEw �Y ' <br />lfAFP,LIC,4NTis not the BILLINGPAR proof of authorization to sign is required Title <br />AUTR0RIXATI0N TO RELEASE INFORMATION: When applicable, X, 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 ENv(RONMEYTAL HEALTH DEPARTMENT as soon as it is available and at the samo time it is <br />provided to me or my representative. <br />=kYfv,ct <br />ate►=-r,--� <br />TYPE OF SERVICE REQUESTED: <br />Commews: <br />jug 2 Q 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />ViEALTH DEPARTMENT <br />ACCEPTED By, ! ` . QIJ �GI/CJ <br />EMPLOYEE #: 31 -1 <br />DATE: 1p lib V <br />ASSIGNED TO: �� Lj ��� <br />EMPLOYEE #: <br />DATE: 6 ?jQ <br />Date Service Completed (If already completed): <br />SERVICE CODE: ' $ <br />I 11E: SO <br />Fee Amount:' 6U <br />Amount Paid , c7-0Payment <br />Date <br />61 C S <br />Payment Type L <br />Invoice # <br />Check # 3 <br />Receiv® d By �j <br />EHD 48-02-025 <br />REVISED 11/97/2003 <br />.� <br />SR FORM (golden Rod) Of <br />