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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />CONTRACTOR / SERVICE REQUESTOR <br />the undersigned property or business owner, operator or authorized agent of same, <br />BILLING ACKNOWLEDGEMENT: I, <br />acknowledge that HEALTH DEPARTMENT hourly charges associated with this protect <br />all site and/or project specific ENVIRONMENTAL <br />or activity will be billed to me or my business as identified on this form. <br />I 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, Standards, STADATE: and FE ERAL laws. <br />APPLICANT'S SIGNATURE: ®/� <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ Title <br />If APPLICANT is not the BILLING PARTY Proof of authorization to sign is required <br />of the property o <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner data operator <br />nd/orenvironmental/site assessment <br />above site address, hereby authorize the release of any and all results, geotechnical <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. _ <br />TYPE OF SERVICE REQUESTED: 5 I t <br />COMMENTS: <br />ACCEPTED <br />ASSIGNED TO: / <br />Date Service Completed (if already completed): <br />Fee Amount: --D�6061c' O Amount Paid <br />Payment Type <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />S V'C I Invoice # <br />RECEIVty <br />APR 2 1 2011 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL_ <br />HEALTH DEPARTMENT <br />EMPLOYEE #: DATE: 2 <br />EMPLOYEE #: 'p DATE: <br />SERVICE CODE: ` P I E. O <br />Payment Date L. f Z ll <br />(Ifik #, (� ►'� S 3 Received By: <br />SR FORM (Golden Rod) <br />