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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR r � l N�� N g �O� g .1 4( 77 7 CHECK If BILLING ADORFSa❑ <br />BUSINESS NAME_ �i _ ^ I ( J IACIQn (' I '/1iC pi q 2,I EXT' <br />HOME or MAILING ADDRESS n , I , , _ . , A .'.\,1 J'r'-- -..I v I�{j r I FAX I 1/11 <br />I CITY C V G My N STATE CA <br />ZIP X''1 Dl/ <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />1 also certify that I have prepared this applic tion and that the>*rk7to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards S E and EEK aws <br />APPLICANT'S SIGNATURE: r/i♦�W/l DATE: <br />PROPERT7'/ BUSINESS OWNER 171 PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br />/jAPPL1C4NT 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 />^I /� NT <br />TYPE OF SERVICE REQUESTED: (ile�(J / �9VL(fliLl'1 <br />COMMENTS: f 11VV// <br />-G(���o,.,� Pck1s <br />MAR 112022 <br />HEALTH <br />ACCEPTED BY: illailyi,4tc'c <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: �U6t, <br />EMPLOYEE#: <br />DATE; — <br />Date Service Completed (B alrilady Completed): <br />SERVICE CODE: S-� <br />p IE: ��00 <br />Fee Amount: <Z, — <br />Amount Paid <br />Payment Date 3 / jp ZZ <br />Payment Type i� <br />invoice <br />ChO64 �J <br />83 �- <br />Received By: <br />EHD 48-02-025 3! 1 (1�v yZ SR FORM (Golden Rod) <br />REVISED 11/172003 j 'rb� q <br />Z`CL <br />