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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE RF011F.RT UUIN IKA(:TOR / SF,RVTCF. RF.n1TF4ZTnR REQUESTOR (j j�/ �+ lj']� COMWKTS: 117,qY 2 4 P��M�SERI%, N�CT CLc� k / ! Gla l l i DATE: ✓� //V� CHECK if BILLING ADDRESS EMPLOYEE #: BUSINESS NAME / / )2(�(Q. ! I /, ,�/ �(� 7 l� PH �# / ��lLl 93 !2 EXT. HOME or MAILING ADDRESS Amount Pai 1(� 1�'"�r� IA -33c- FAX # ) Payment Type / f CITY l/� 1�/Ly L/ Check # STATF�p Gj 2 / `' ZIP ro-30 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: CICU d(Q () yln�u DATE: 'S I Zi t � I '(� PROPERTY I BUSINESS OWNER Of OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Till e 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 a it is provided to me or my representative.^ ` l Q TYPE E OF SERVICE REQUESTED:Ly COMWKTS: 117,qY 2 4 P��M�SERI%, N�CT CLc� k ACCEPTED BY: EMPLOYEE #: DATE: ✓� //V� ASSIGNED TO: Ovta EMPLOYEE #: -�'� , /'! DATE: Date Service Completed (if already completed): SERVICE CODE: t5Z =P/E: l &01 Fee Amount: !—y �� Amount Pai Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) %1NM