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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST CONTRACTOR / SERVICE REQUESTOR REQUESTOR e/► i � I S Lam+" BUSINESS NAME ROME or MAILING ADDRESS CITY bood'Y el OOYado si- C14ECIK If BILLING ADDRESS PHONE f EXT. u 3 2. FAx # STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Godes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY) BUSINESS OWNER ❑ OPERATOR—MANAGER ❑ OTHER AUTHORIZEDRGENT —rLh- �bY If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: ACCEPTED BY: ASSIGNED TO: 111 I Date Service Completed (if already completed): Fee Amount: Amount Paid EMPLOYEE #: EMPLOYEE #: Payment Type .-, _l Invoice # Check # EHo 48-02-025 07117!08 OCT 0 5 2017 -`'t Oct ENVIRONMENTAL HEALTHSI,,13 PERMIT/SERVIC�S h EAyvR QUiN STH r°'vtitFn SERVICE CODE: Payment Date DATE: DATE: I t }V I 1 P1E:l )of,3�17 Received By: SR FORM (Golden Rod)