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SAN JOAO '�OUNTY ENVIRONMENTAL HEAL,* ?ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />GtAs -51ATLetJ <br />FACILITY ID # <br />-7 <br />SERVICE REQUEST # <br />aw�olc i(A-st-ttJakLb-LA 0 t� �1� �Ir_o <br />-3 ti:) <br />BUSINESS NAME <br />S,CC <br />mat, <br />SRO 0 5355 <br />OWNER/ OPERATOR <br />TV --0 6- � C, t <br />CHECK If SILLINQ ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />Stmet Number T&Nstreetwrne <br />.)a - is <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />SVL/L <br />cily • <br />L L4 A V-e— <br />treef N—h- <br />ACCEPTED BY: 0D 0 F- i ke-o4 <br />CITY CO-V--�,CtA <br />STATE zip <br />PHONE #1 EXT. <br />APM # <br />2- - 1? 0 -,S 0 <br />LAND USE APPLICATION III <br />PHONE #2 ExT. <br />BOS DISTRICT <br />L AT1914 CODE <br />REQUESTOR <br />TYPE OF SERVICE REQUESTED: <br />L-4& LA6 16 cr� *0% <br />aw�olc i(A-st-ttJakLb-LA 0 t� �1� �Ir_o <br />CHECK If BILLING ALDR. SUP <br />BUSINESS NAME <br />S,CC <br />mat, <br />o,m <br />PHONE # <br />LOY) <br />Ex,. <br />A 7� <br />HOME or MAILINGA DDRESS <br />FAx 9 <br />( *% <br />.)a - is <br />CITY <br />�5a,,A. <br />,� C) -P-- STATE CA, <br />zIP q <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: LTv- u D . ATE:-4�Lazb-v <br />PROPERTY I BusiNEss OWNER 13 OPERATOR/ MANAGER [3 OTHER AuTHoRizEDAGENT R1 0-0w-DLL0-'"-(-4 &(Qle� <br />If APPLICANT is not the =ffg—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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. U c -t- ao ,� -t--A - —r- ,-I- — <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod) <br />TYPE OF SERVICE REQUESTED: <br />L-4& LA6 16 cr� *0% <br />aw�olc i(A-st-ttJakLb-LA 0 t� �1� �Ir_o <br />COMMENTS: <br />7zUU <br />SPN J()PQ1J1Noo <br />ONMEN'TAL <br />ET4\J1 <br />VaME <br />TVA [)F-PPAX <br />ACCEPTED BY: 0D 0 F- i ke-o4 <br />EMPLOYEE <br />DATE: 3 -7/0 <br />ASSIGNED TO: e1, <br />EMPLOMPLO YEE <br />nA-rs:- <br />WO <br />Date Service Completed (if already completed): <br />-Amount <br />SERVICE CODE: <br />P/E: <br />I <br />Fee Amount: ;DT q-. u ® I Paid <br />Payment Date <br />31 A& <br />Payment Type <br />Invoice # <br />Check# <br />Received By: -r <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod) <br />