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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REOUEST CONTRACTOR / SERV1(:�: K>Jt1uI;s1<vK REQUESTOR � r, �7 � ��r�w � CHECK If BILLING ADDRESS�J Y/V � PHONE # p ExT. BUSINESS NAME 20 °( �3'o - 9Y� 1 C 44 HOME or MAILING ADDRESS 44-711 / l v E � �T - K ,Q PI iV (� ) CITY '1 v (l` C•C 7 , " v 1 ` r STATE (11�- ZIP gf z/ "Z 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. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: c DATE: PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 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 enviromnental/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. L TYPE OF SERVICE REQUESTED:&� y� s(I fA 1 a - COMMENTS: I PAYMENT RECEIVED ACCEPTED BY: ASSIGNED TO: %^ Date Service Completed (if already completed): Fee Amount: � 6a F Amount Paid Payment Type /' L, L I Invoice # EHD 48-02-025 REVISED 11/17/2003 MAR 18 2022 EMPLOYEE #: E UNI EMPLOYEE #: DATE: 3 P 2 SERVICE CODE: <—a 3 P I E. r O p? (�® Payment Date 3 Z o Check # 7 Received By: SR CORM (Golden Rod)