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0 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REQUESTOR <br />RECIUESTOR 7. <br />i% f <br />PAYMENT <br />rCHEexifBILLING AoDREss <br />CHECK <br />BUSINESS NAME <br />' JUN z 8 2012 <br />PHONE# ExT. <br />1O1V1E Or MAILING ADDRESS <br />r L"�� <br />�j <br />. J 4 11 <br />✓ f <br />( '!Fl"'( ) el e71K'J - <br />CITY �/ ' <br />L. -I & fir,: y 'i i !✓ 4/ 0 <br />STATE ��' zIP 51S -73T <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 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 aws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ ` OPE WAGER ❑ OTHER AUTxORIZEII AGEYTTZ c.•/V Y IG <br />IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: i'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 environmentaUsite 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: <br />PAYMENT <br />COMMENTS: <br />' JUN z 8 2012 <br />SAN JOA QURN CCUWrY <br />EHYI R'0 N M ENTAL <br />HEaLTH DEPARTMENT <br />ACCEPTED BY:f V� <br />EMPLOYEE#. �1, <br />DATE.-g(1'7— <br />ASSIGNED TO: f u /+p ) <br />EMPLOYEE M <br />DATE: to Z g <br />i -I_ <br />Date Service Completed (if already completed): <br />SERVICE CODE: I qr <br />P 1 E: <br />Fee Amount:/ Amount Paid <br />Payment Date <br />� �Z <br />Payment Type , Invoice # <br />Check # -'� j <br />Receiwd By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 1111712003 <br />