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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST �n�rrru Af''TnR / CF.RVT('.F. RF,(?11L+'S"1'UK BILLING ACKNOWLEDGEMENT: I, the unde d property or business owner, operator or sutnorizea ugCut ul aQa.,u, acknowledge that all site and/or projects ecific V. or activity will be billed to me or my bus ness den I also certify that I have prepared this a Lica and COUNTY Ordinance Codes, Standards, Th d FE) MENTAL HEnL'rt-r DEpAR'riviENT hourly charges associated with this project ion this form. the work to be performed will be done in accordance with all SAN JOAQUIN L laws. APPLICANT'S SIGNATURE DATE: ---- PROPERTY / BUSINESS OWNER❑ P TOR / MANAGER ❑ OTHER AUTHORIZED AGENT W Z t�� LICANT is not I BI GING PARTY proof of authorization to sign is required Title If APP P 1 AUTHORIZATION TO RELE E 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 environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it 1S available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: L! { pAI( r� r� COMMENTS: FEN 2 �J�p99 SAN JOA UIN QUIh ENVIR�`� y OA' HEAl.THDEP EN 1'A i_ Al2 t MEtli ACCEPTED BY: EMPLOYEE #00 DATE:L� ASSIGNED TO: ViL y�eL. EMPLOYEE #: DATE: 2 �� Date Service Completed (if already completed): SERVICE CODE: P E: Fee Amount: � "? Amount Paid Payment Date VI Payment Type j Ste, Invoice # Check #.LW 12, ?, U Received By: EHD 48-02-025 IVI G L U,2*1� G y ✓� /� SR FORM (Golden Rod) REVISED 11/17/2003 aG17 V V l \ Jl ice. a v a a � • .....-... � � � � -- � .- REQUESTOR —Ar"t �-a. 2IZry a ze& A CHECK if BILLING ADDRESS PHONE # En' BUSINEss NAME l � 1 �"��5 Z!A q Q oz'00 HOME or MAILING ADDRESS 2.11 I ted FAX# ( ) R ir11 f�07 CITY J �� Jif Ors 1 STATE C A zip 17 33IN -ffl BILLING ACKNOWLEDGEMENT: I, the unde d property or business owner, operator or sutnorizea ugCut ul aQa.,u, acknowledge that all site and/or projects ecific V. or activity will be billed to me or my bus ness den I also certify that I have prepared this a Lica and COUNTY Ordinance Codes, Standards, Th d FE) MENTAL HEnL'rt-r DEpAR'riviENT hourly charges associated with this project ion this form. the work to be performed will be done in accordance with all SAN JOAQUIN L laws. APPLICANT'S SIGNATURE DATE: ---- PROPERTY / BUSINESS OWNER❑ P TOR / MANAGER ❑ OTHER AUTHORIZED AGENT W Z t�� LICANT is not I BI GING PARTY proof of authorization to sign is required Title If APP P 1 AUTHORIZATION TO RELE E 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 environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it 1S available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: L! { pAI( r� r� COMMENTS: FEN 2 �J�p99 SAN JOA UIN QUIh ENVIR�`� y OA' HEAl.THDEP EN 1'A i_ Al2 t MEtli ACCEPTED BY: EMPLOYEE #00 DATE:L� ASSIGNED TO: ViL y�eL. EMPLOYEE #: DATE: 2 �� Date Service Completed (if already completed): SERVICE CODE: P E: Fee Amount: � "? Amount Paid Payment Date VI Payment Type j Ste, Invoice # Check #.LW 12, ?, U Received By: EHD 48-02-025 IVI G L U,2*1� G y ✓� /� SR FORM (Golden Rod) REVISED 11/17/2003 aG17