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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br />CF.RV-trF RF,OUEST <br />CONTRACTOR /SERVICE x>H;tlu>iJsrUx <br />REQUESTOR `�� CHECK if BILLING ADDRESS <br />EXT <br />BUSINESS NAME ` \ PHONE # <br />HOME or MAILING ADDRESS FAX # 5 # <br />CITY STATE ZIP C4,C <br />J <br />Ct <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 <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, STA and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: �' U <br />CCTe <br />PROPERTY/ BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Y4 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tule <br />AUTHORIZATION TO RELEASE 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 environmental/site assessment <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.S� �C l <br />TYPE OF SERVICE REQUESTED: l5\ <br />R ' <br />COMMENTS: <br />UNN <br />gAN JOAPONMEN MENT <br />EN�N pEPA� <br />ACCEPTED BY: i <br />EMPLOYEE #: DATE:, 3i <br />ASSIGNED TO: <br />EMPLOYEE #: % ^-� DATE: 3Q <br />� �- I t. ,) �� ---CC' <br />SERVICE CODE: P / E. <br />Date Service Completed (if already completed): P <br />Payment DateAmount Paid dFee Amount"f 4 -U I <br />Payment Type Invoice # Check # Received By: <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />EVISED 11/17/2003 <br />