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i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST CONTRACTOR / SERVICE REQU ES'FOX REQUESTOR1'12 � CHECK if 81tLiNG ADDRESS I,..I P�e�1 En. BUSINESS NAME -e—VZej��y� Hone or MAILING A DRESS 1 C b)' r`�1�.11 1, c —rv- I r xa z STATE QIP CITY ,\j . 4!WcA Ow `7 )- l BILLING ACKNOWLEDGEMENT: 9.. the undersigned property or business owner, operator or authorized agent of same, ackno%vledge that all size and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated With this project or activity will be bilied to me or my business as identified on this form. I also certify that I have prepared this application and that the worst to be performed will be done in accordance vAth all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATS and FEDERAL Iaws. / APPLICANT'S SIGIqATURE: � �vt - ❑A7E�:y PROPERTY I BusINEss OWNER ' PERATOR I RIANAGER OTHER AUTHt7Ri7EA AGEiii Li if APPiJCANT is net theBaLur4�G PARTY. proof of authorization to sign is required Titl c AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment information to the SAN JOAQUIN COUNTY EuviRONMENTAL HE1\LTH DEPARTMENT as soon as It is aVallable and at the same time it Is provided to me or my representative. �1!i,ro �� RENr rTYPE,OFERVICE �REf1t1E5TEU: D�L '/ V + � 2013 4+4�0� U N Z iJ ACCEPTED BY: EmPLOYEE lf: j i� DATE: f '� JI Gti ' 13 - ' .f(p, ti i.- AssIGNEaTO; �} �C> EMPLOYEE M. ' Geoff I]aTE. �Z�iU 13 Date Service Completed (if already compteted): SERVICE CODE: 3 U� Fee Amount: 3 7,— Amount Paid -Z j dD Payment Date 1,2- # ,2 13 Payment Type Inveice # Check # (o f Received By: EHD 48-02-025 p71t71OR SR FORM (Golden RW)