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JAN JOAQUIN (:OUNTY ENVIRONMENTAL HEALTH D"PARTMENT SERVICE RFOTTF.cT UO1VTRAC:TOR / SF,RVTCF, R1F,0TTF.cTn1D REQUESTOR RECE-1 — COMMENTS: ,� � �, W,�V✓ 1 ACCEPTED BY: CHECK It BILLING ADDRESS BUSINESS NAME Se�rv�C�. S ASSIGNED TO: PHON �{oy EXT. . ai3- 03 P HOME or MAILING ADDRESS D O SERVICE CODE: FAx# ('4oy 1 �t3-- (Qqo kb CITY C � r O --. STATE OX ZIPa-- BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUrN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPI:ICANT.'S 'SIGNATURE:' . " ' • • �.Ll DATE:... PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IJ CLCyt Lt(QL(JLL•Qy �'tC!�Y If APPLICANT is not the BILLING PARTY. proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. PAYMEN- TYPE OF SERVICE REQUESTED: f +Urm U RECE-1 — COMMENTS: ,� � SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P / E: 2 Q Fee Amount: (/i Amount Paid Payrnenf Date Payment Type ✓ Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)