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11I V`t! LV VY VJ. JL LV J`1V VJYJJ rlr In rLUUM <br />ft SANJOA,QUIN NTX EN IRONMEIwTAL HEALT D AItTMENT, <br />SERVICE REOUEST <br />r" Akar- rpt <br />CONTRACTOR/ SERVICE REQUES'rUR <br />ftQUESTQR�i o� �4 N`� I CHECK if BILUNG ADOREssL)A <br />l 1. PMQNE#_ �4 a�EXT.Z � <br />BUSINESS NAME _ O � 1 � <br />SS 1— <br />HomE or MIUUNG ADDRESS — FAX # _ <br />CITY b V) 6�- )Q STATE (: f\ 7JP J4�7 <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 EN VIRONMEN TSL H>-ALTH DEPARTMFNr hourly charges associated with this projector <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application aqd that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE an ED a <br />ArrLICArirs SIGNATURE: Z: - � _ <br />PROPERTY / SUStTiE$S OWNER D OPERATOR /MANAGER 0 OTHER AUTHORIZED AG>.1`1T, <br />1f APPLrCANT is not the BJLtlNG PARTY proof of authorization to sign is required Tirle <br />'rHORIZATION TO RETLEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environrnental/site assessment <br />information to the SAN JoAQuN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. _ <br />TYPE OF SERVICE REQUESTED: <br />COMYENTs: <br />ACCEPTED BY: <br />ASSIGNED TO: <br />Rate Service t <br />Fee Amount: <br />Payment Type <br />EHD 4"2-425 <br />REVISED 17/1712003 <br />(If already completed): <br />invoice # <br />Amount paid <br />C-- (*,, K, L <br />PAYMENT <br />FEB 18 M5 <br />I-Ani11N COUNT`( <br />EMPLOYEE M l DATE: 1-1,aH . F-- <br />WEL <br />i~MPLOYEE #: DATE: <br />SEIMCE CODE:` PIE: <br />Z <br />a �g Payment pate <br />Check # �$' Received By: <br />SR FORM (Golden Rod) <br />