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SAN JOAQUIWOUNTY ENVIRONMENTAL HEALTH WARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />K a-v4q <br />SERVICE REQUEST # <br />_ IS STATLoK1 <br />CHECK If BILLING ADDRESS i) <br />BUSINESS NAMEc <br />Seu,vt <br />3-7 r -C' <br />SR0053551 <br />OWNER/ OPERATOR <br />Steel( Gl <br />�Vb�I�C t <br />' t t V Avg. <br />CHECK If BILLING <br />FAX# <br />S <br />CITY <br />V <br />ADDRESSO <br />Faclurr NAME <br />ZIP c� f <br />C: `l f / <br />E [ I� <br />.L 1 v � <br />G <br />EMPLOYEE #: (L, -t <br />SITE ADDRESS 73--1 a S t;� <br />Street Number irection <br />� t t ` <br />t <br />� C� q � X, <br />Streeta <br />HOME Or MAILING ADDRESS (If Different from Site Address) � � n �� � 5 , <br />Cit i a <br />w < < w1 <br />CITY <br />SERVICE CODE: �7 <br />Street Number() <br />U <br />r teme <br />Ca.lsso►� <br />l , Payment Date <br />3 1 q1 6 <br />STATE <br />Ct4 ZIP <br />PHONE #1 E'R <br />(� �) t (0,. <br />APN # <br />Z r Z i <br />-7 Cl — �, <br />LAND USE APPLICATION # <br />PHONE #T EXT. <br />SOSDISTRICTLOCATI3�QN <br />CODE <br />CONTRACTOR / SERVICE RF.nTT1FQTnu <br />REQUESTOR <br />TYPE OF SERVICE REQUESTED: <br />of �� <br />K a-v4q <br />COMMENTS: <br />CHECK If BILLING ADDRESS i) <br />BUSINESS NAMEc <br />Seu,vt <br />arc vvl s�('J()7)at <br />IL <br />PHONE # <br />EXT. <br />3 s (CC 3 <br />HOME or MAILING ADDRESS <br />to <br />' t t V Avg. <br />FAX# <br />1co a. <br />CITY <br />V <br />STATE CA, <br />ZIP c� f <br />C: `l f / <br />1 I1J,1 rls AC:." V WLEDGEME' NT: 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: 1,4__ '��1"1 (,' `; '- zti -i <br />DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT R1CO LtA (J� t Iti C� U�t tic ei� <br />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. Ct S -r-l .2 I ,T_ — <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod) <br />TYPE OF SERVICE REQUESTED: <br />of �� <br />` <br />o i.1.�5t�a-�t.L`rn AIME <br />COMMENTS: <br />MAtt _ i t;JU6 <br />SANJOAOUIN COUNTY <br />ENVIRONMENTAL <br />H DEPARTME <br />ACCEPTED BY: <br />E [ I� <br />.L 1 v � <br />G <br />EMPLOYEE #: (L, -t <br />DATE: 'j 7 �l <br />Lo <br />ASSIGNED TO: <br />� F- /-J %--' 7 <br />EMPLOYEE #: S � � Z <br />DATE: d <br />Date Service Completed (if already completed): <br />SERVICE CODE: �7 <br />P / E: <br />Fee Amount: <br />r U o Amount Paid <br />l , Payment Date <br />3 1 q1 6 <br />Payment Type <br />vj <br />Invoice # <br />Check # a Z <br />Received By.� <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod) <br />