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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REOUEST <br />CONTRACTOR / SERVICE KEt2UES IUK <br />REQUESTOR \ I ` \ CHECK if BILLING ADDRESS® <br />PHONE # Exr. <br />BUSINESS NAME \ —i <br />\� FAx # <br />HOME Or MAILING ADDRESSp (Q (" 1 ^)� J <br />1� STATE ZIP � Jr(el` ` <br />CITY S C <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner; operat�o,a,�r authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEP , M 1 -� s associated with this project <br />$__�'` <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 perfom d1will bg dotW in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Stand TATE and FEDERAL laws. F ---N 1 ` ± <br />ViRO�i�,��_.N . �-iEFI�. N _ 3y- y8 <br />APPLICANT'S SIGNATURE: F ,,� i j _ \ <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 171`�GY�CQ 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: r <br />JOAau1N COON <br />SA ENVIRONME TMENT <br />HEALTH 0EI'AR <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />I` ASSIGNED TO: Pr�EMPLOYEE #: y b' j DATE: <br />I <br />Date Service Completed (if already completed): SERVICE CODE: PIE. <br />iPayment Date <br />i Fee Amount: Amount Paid <br />.,_•. ___. T....., L,.,�he If Check # Received By: <br />