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� � i its ,. <br />t <br />SERVICESANJOAQ COUNTY ENVIRONMENTAL HEALP*,Y, EPARTMENT <br />r <br />--MI <br />■ <br />I <br />�I <br />OVMER I OPERATOR CHECK If BILLING ADDRESS <br />SITE <br />ADDRESSStmet Number M <br />HOME or MAjuNG <br />ADDRESS (if Different from Site Address) <br />i <br />Win <br />NilLOCATION• e <br />' R <br />REQUEISTOR 00,,. <br />HOME or MAILING ADDRESS - <br />B NG 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, STATE and FEDERAL, laws. O� <br />APPLICANT'S SIGNATURE: Q DATE: <br />PROPERTY / BusiNEss owNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT®® \S\ • C�ISYC�• . <br />If APPLICANT is not the BILLING PARTY. proof of authorization to sign is required Title <br />AUTH91UZATION TO RELEASE INFORM&TJQN: When applicable, I, the owner or operator of the property located at the <br />above site address, .hereby authorize the release of any an ata and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL H as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: ST f. 7— MAY U 1 (.UUJ <br />coilMEfiTs. ® `al n ca <br />pia � L` �, �,,•�,r\,p �1re S. �1So?s ��� � \,; o�e.� �,\ . <br />ACCEPTED BY: (_ i ✓ t i®— EMPLOYEE #: 3 j <br />DATE: <br />ASSIGNED TO: O'4 ey, EMPLOYEE : <br />DATE: S (l ® ! <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P i E:3U <br />Fee Amount: 3 1p <br />Amount Paid $- <br />Payment Date S101 <br />Payment Type <br />Invoice # <br />Check `f 3 4 L 9 <br />lkeaei !/M E <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 MAY 1 2009 <br />SAN JOAQUIN COUNTY <br />r►i%nonmhAFNTAI <br />