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10/14/2004 11:54 464013�i8i�T <br />,,144 L'\':. <br />�+ <br />ENVIRONMENTAL HEALTH PAGE 02 <br />',' kTMEN.T <br />SERVICE R0TIEST <br />CONTRACTOR / SERVICE RE, QUESTOR <br />REQUESTOR <br />C 1ECKIf 81�61Nc3 AD�REss <br />BuSINEss NAmU �1 <br />cx <br />HOME or MM,,W9 ADDRE PAY 2 <br />CRY STA <br />PILLING CKNO EUGENE : 1, the undcrsigued property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENMONMGNTAL HEALTH DEPARTMENT hourly charges associated with this project or <br />activity will be billed to me or my business as identified on is form <br />I also ecr* that I have prepared thisation and tha a wok to be performed will be done in accordance with all SAN JQAQM <br />COWT V Ordinance Codes, Stand ISATE and E laAPPLICANT'S SIGNATURE: ^ DA <br />)PROPERTY I BUSiNIRM OWNERVot <br />OPERATOR / N1' 4AGER D OTHER AirritoRmm AGFNf�' <br />If APP.UCANT.e BILLING PARTY proof of authorization to sign is required rir[c <br />A!aH0RI7ATJ0N TO MT.EASE INFORMA'IiTON: 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, geotecWcal data and/or eavirowl atallsite assessment <br />information to the SAN JoAQvEN CoLwN ENVIRONMENTAL, HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representativc. <br />TYPE of SERv10E REQUESTED: J > f <br />' ct✓� R �I ' -> <br />COMMENTS: <br />v <br />OC _ C <br />152004 <br />SAN JOAQUcWV/RI <br />HEq <br />TN P R � CNS, <br />N <br />ACCEPT® BY , _ ,� -'� �� . _ <br />EMPLOYEE #: <br />DATE: �) S , 1 <br />ASSIGNED TO: f <br />EMPLOYEE #: DATE: <br />Date Setvlce Completed (if already completed): <br />SERVICE com j � P t I- <br />Fee Amount: C <br />Amount Paida <br />Phyrnent Date <br />Payment Type <br />Invoice # <br />Check <br />Received By: <br />FHD 4"2-025 SR FORM (Golden Rodl <br />REVISED 11(17!2003 <br />