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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REOUESTOR <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 or <br />activity will be billed to me or my business as identified on this form. <br />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. <br />APPLICANT'S SIGNATURE: 1 DATE: <br />PROPERTY I BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ / <br />If APPLICANT is not the _BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site as ent information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time I %y <br />p� or <br />my representative. �tl� <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: <br />ASSIGNED TO: l <br />Date Service Complete (if already completed): <br />Fee Amount: I Cab Amount Paid <br />Payment Type (7 /� Invoice # <br />i <br />EHD 48-02-025 <br />07/17/08 <br />EMPLOYEE #: <br />EMPLOYEE #: <br />SERVICE CODE: <br />), O� I Payment Date <br />Check# /r) <br />SAN dOAQU--" <br />Ejvv/aIN C <br />E4L'-" PAR O1VMEMSN- <br />DATE: <br />-)/- / _i-7 <br />DATE: - / - / -�' <br />PIE: <br />f l 1 _" <br />Received By: <br />SR FORM (Golden Rod) <br />