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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME > <br />Z��y lr1 /11*s �. <br />FACILITY ID # <br />SERVICE REQUEST # <br />.e3-(-6-Ly-a -t <br />CITY L IYU STATE C ZIP 75-3--'D <br />Sir) ao--f� (57c) <br />OWNER I PPERATOR <br />N� <br />y+ <br />CHECK <br />Si � H � i -•e <br />�r 7-z� USA - <br />EMPLOYEE #: <br />DATE: <br />If BILLING ADDRESS <br />FACILITY NAME <br />DATE: <br />Date Service Completed (if already completed): <br />SITE ADDRESS <br />I <br />3n <br />L41 (� <br />Amount Paid <br />Payment Date <br />Street Number <br />Direction <br />Check # <br />Street Name <br />c1tv <br />Code <br />HOME or MM/AILING ADDRESS (if Differentffrom] <br />Site Address) <br />55RI <br />uy.S Ej ,"I <br />✓�+ r fCXJ� {.tw' LJ L4 <br />&free[ Numher <br />jr, <br />Street Name <br />CITY r ,yam <br />ch A -33o <br />PHONE ##1 EXT. <br />API <br />LAND USE APPLICATION # <br />c 20 has —Z2S� <br />f -zqo - 05-0-0ol <br />PHONE 92 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR 1 SERVICE REQUESTOR <br />RIEQUESTOR <br />CHECK if BILLSNG ADDRESS <br />l 1 <br />BUSINESS NAME > <br />Z��y lr1 /11*s �. <br />PHONE# EXT. <br />'{D5 —7z -Ss - <br />HOME Or MAILING ADDRESS <br />FAR# <br />CITY L IYU STATE C ZIP 75-3--'D <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 or <br />activity will be billed to me or my business as identified on this form. <br />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, TATE and FEDERAL laws. G <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR I MAN R OTHER AUTHORIZED AGENT ❑ ?/t5lde. T{ <br />IfAPPL1CANT is not the BILLING PARTY, proof !'uthorization to sign Is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property 1 cated at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite ,a.,Is� t information <br />t0 the SAN JOAQWN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon a5 It Is available and at the same tlmE�j[; dome Or <br />my representative. 4t .1. /�`���// <br />TYPE OF SERVICE REQUESTED: <br />40 <br />COMMENTS: <br />��EpgR�Ny� <br />N� <br />NT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received i3y: <br />EHD 48-02-025 <br />07117!08 <br />SR FORM (Golden Food) <br />5 <br />