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SAN JOAQUIN B=OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />40 SERVICE REQUEST <br />ncs\,If <br />CONTRACTOR / SERVICE REQUESTOR <br />11117 ( V 1 / 1 D'C— <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />d/or project specifL IRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />acknowledge that all site an <br />or activity will be billed to me or my b ess aside ified on this form. <br />I also certify that I have prepare is application d that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Stan , STATE d FEDERAL. laws. fjD <br />I , 10 <br />APPLICANT'S SIGNATU HORIZED AGENT <br />PROPERTY / BUSINESS OWNER❑ OPE AGER 13 OTHER AUT <br />Title <br />authorization to sign is require <br />If APPLICANT is of the proof of BI 1 PAR <br />AUTHORIZATION TO RE SE TION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize a ease 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. <br />TYPE OF SERVICE REQUESTED: v �, <br />COMMENTS: �he a\ <br />�& pAwv4oe d Cr -,Au V aA--. <br />ACCEPTED BY: <br />ASSIGNED TO: <br />Date Service Completed (if already completed): <br />Fee Amount: <br />Payment Type <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />Invoice # <br />Amount Paid <br />EMPLOYEE #: <br />EMPLOYEE #: <br />SERVICE CODE: <br />Payment Date <br />Check # <br />DATE: <br />DATE: <br />PIE: <br />Received By: <br />SR FORM (Golden Rod) <br />