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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTi.-)EPARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE <br />_... "UYvet <br />BILLING ACKNOWLEDGEMENT: I, the Undersigned property or business owner, operator or authorized agent of same, <br />AL HEALTH DEPARTMENT hourly charges associated with this project <br />acknowledge that all site and/or project specific ENVIRONMENT <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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. L <br />DATE: ' <br />APPLICANT'S SIGNATURE: v <br />PROPERTY /BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHERAUTDORIZEDAGENTE� eI G <br />IJArrcrewT is not the Bttcmvc PARproof of authorization to sign is required Title <br />TY, <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site <br />d/virormTentaUsite assessment <br />address, hereby authorize the release of any and all results, geotechnical data anor en <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 />nn... o <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />JUL 0 1 2019 <br />ENVIRONMENTALDEPAME HEALTH <br />Cl(\(`��\1\J <br />DEPARTMENT <br />EMPLOYEE#: v 3 DATE: ' <br />ACCEPTED1BY:EMPLOYEE M �LDATE:ASSIGNED <br />Date Service Completed (If already completed): <br />SERVICE CODE: �'L Pi <br />Fee Amount: <br />Amount Paid 30<1 (DD I <br />Payment <br />Payment Type �� <br />Invoice # Check #,3536 <br />SR FORM (Golden Rod) <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />