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• •. <br />SAN JOAQUIN COUNTY ENvIR,014MENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REQ) U EN't utt 441 <br />REQUESTOR(� CHECKN&LLIN <br />f'IIONE # <br />BUSINESS NAME 70 _ L, - <br />HOME or MAIUNG ADDRESS Y FAX # <br />CITYSTAT ZIP e) <br />C/ <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 or <br />activity will be billed to me or my business as identified on this form. <br />1 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, Staniardd s,, ASTATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: z (� DATE: � `" �►S� `� C�� <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHOR!-Zro CENT ❑ <br />If APPLICANT iS 1701 U7e BILLING PARTY, proof of authorizab'-rr io s; jn is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br />site address, hereby authorize tale release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is Rv,�ila b1e and at the same time it is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: T t <br />COMMENTS: — . I �'— <br />EASSIGNED <br />BY: r EMPLOYEE#: DATE' <br />TO: EMPLOYEE 9' DATE: <br />ice Completed (if alrc3d complet d): <br />�rRVICECoDr: PIE: 2303 <br />Fee Amount: �� d J Amount Paid Payment Date oZ <br />Payment T h7voice # Check # x ed B <br />Y Type <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod) <br />DEC 0 5 2014 <br />ENVIRONMENTAL HEALTH <br />