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SAN JOAQULN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />D <br />l Z- <br />FACILITY ID � <br />SERVICE REQUEST # <br />4 <br />PHONE # EXT. <br />g b S = / z. Lt b <br />HOME or MAILING ADDRESS <br />(.L&I� �E <br />FAX # <br />5&052-7 8 <br />OWNER /OPERATOR <br />(p�i� 1 � (� J--1 S� 3 <br />CITY <br />r rE ZIP 5 O <br />1� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME S <br />u, mac, l�- <br />DATE: D <br />ASSIGNED TO: /� <br />SITE ADDRE <br />/09,58 <br />EMPLOYEE #: 7� 3 <br />t <br />DATE: t1 3o d7 <br />Date Service Completed (if already completed): <br />Street Number <br />Direction <br />Street <br />Name <br />Cit <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />I <br />Received By:. <br />Street Number <br />Street Name <br />CIN <br />STATE <br />ZIP <br />PHONE#1 EXT. <br />A PN # <br />LAND USE APPLICATION # <br />( 1 <br />C &C' - <br />p �i0- 1.S <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION ODE <br />CONTRACTOR / SERVICE REQUFSTOR <br />REQUESTOR <br />D <br />l Z- <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />iL�n l0 <br />NOV 3 0 200 3 0 <br />PHONE # EXT. <br />g b S = / z. Lt b <br />HOME or MAILING ADDRESS <br />2 <br />ENVIRONMEN-, <br />MFN0� <br />FAX # <br />C0� � E Lac-�ck✓� <br />' <br />PERMIT/SER pgRTMF <br />(p�i� 1 � (� J--1 S� 3 <br />CITY <br />r rE ZIP 5 O <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 />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. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTIIER AU'T'HORIZED AGENT a iii LG��G� <br />//'APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 COUN'rY ENVIRONMENTAL HEAI:ri-I DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. q Y <br />TYPE OF SERVICE REQUESTED: L(S �! Q� �/ �� �D y�r �/ OT <br />COMMENTS: <br />EHD 48-02-025 � rt S7'tZ'r l /� �. <br />REVISED 11/17/2003 �/ Z SSR FORM (Golden Rod) <br />a� w,y <br />0? <br />7k <br />NOV 3 0 200 3 0 <br />2 <br />ENVIRONMEN-, <br />MFN0� <br />' <br />PERMIT/SER pgRTMF <br />ACCEPTED BY: O L t y F-1 V-4 <br />EMPLOYEE #: O 3 <br />DATE: D <br />ASSIGNED TO: /� <br />EMPLOYEE #: 7� 3 <br />DATE: t1 3o d7 <br />Date Service Completed (if already completed): <br />SERVICE CODE: c1 <br />P / E: <br />Fee Amount. v�gt�• oV Z <br />Amount Paid cA-) <br />Payment Date <br />Payment Type t� <br />Invoice # <br />Check # (07(o <br />I <br />Received By:. <br />EHD 48-02-025 � rt S7'tZ'r l /� �. <br />REVISED 11/17/2003 �/ Z SSR FORM (Golden Rod) <br />a� w,y <br />0? <br />7k <br />