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0 <br />SAN -JOAQUIN COUNTY FNVIRONMEN'FAL IIEAum DARTMICNT <br />SERVICE REQUEST_ <br />BILLIN-9-G C OWL E E 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL 1-1r;ALTH 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 JOAQ1.JlN <br />COUNTY Ordinance codes, Standards, STATLand FEDERAL laws. <br />APPLICANT'S SIGNATURE: i&nta DATE:, <br />l'R0PBRTV/BUS1Nrw830wNER11 OprRATOR/ MANAGER [3 0TuERAuTHoRizrnAcENT <br />If APPLICANT is riot the A2&LLQ81Rry, proof of authorization to sign is require <br />ANTHORIZA1, 0 0 REL When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorizethe, release of any and all results, geotechnical data and/or environmentaUsite assessment <br />information to the SAN JOAOIJIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is <br />provided to me or my representative. 7 <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS. <br />�y <br />ACCEPTED BY: 0 L-( klE I <br />Assir.NED To. O -ACA -P <br />Date Service Completed Jif alroady comPlOted).: A <br />Fee Amount , :5 Ba C — ---Amount Paid <br />Payment Type Invoice # <br />[a <br />[EiMPLOYEES: WlE: f 0 <br />EMPLOYEE DATs: -fi—Lfi- I _0 <br />-- SERvicr! CODE: P1—: 230e' <br />7� Payment Date <br />: <br />RReceived�133 <br />Y <br />Check # KA it,—' <br />SR FORM (Golden Rod) <br />EHD 48-02425 <br />REVISED 11/17/2003 <br />