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Feb 25 03 01 : 3710 RG SPRNOS JET CENTER (2f(c' . 983-4710 P. 3• <br /> FEB 24 2003 3: 00PM S46C0 2094649 p- 2 <br /> I <br /> SAR j'UAQU1N COUNTY LNVIRONM1✓NTAL HEAUIT!, DEPA1t•I'tY LN'1• <br /> S r'RVICE REQUEST <br /> Type of Business or Properly FACILITY ID f —" <br /> SERVICE REQUEST Y <br /> 4I�l:k--;'� jL..A:i'� •t Llt�-� ''`rim � :-���4=�> <br /> �1 <br /> WNEA FEAATOR <br /> lJ, 7 \ ��' S GNECX.!BItuNG A ssess � <br /> Fxu.rT`f NAME r <br /> SrTE A9uHESS <br /> I !, <br /> VU Sl.:[I+r v..+Lr•. Olrc Sloq 4 I�INam� 1 <br /> ``yycn- n torr <br /> r7oME Or)AA}Li1iC;ADDRESS (If Different from 5110 Adilressl " <br /> ITV SI Nl rnpCl >trCCl�!_91L. <br /> STATE zip <br /> IIp'OHE Yt • Ctr• AWN X LANA USE APPUCAT10N p <br /> !iE 12 E;r DOSDISTRICT <br /> I LaCnTIaN GOaC <br /> t <br /> NTR 'CTQ SERVICE+' REQUI:STOR <br /> EOUE&TOR <br /> l <br /> r CKCK1I dILLIVG Af7a0.L55[ <br /> tUS711NESS AME 1 PMONE p I Er+. <br /> c.1 Tbz 2'Il cYf—/��7ri., �. 5 TZ <br /> 10ME Or h1Alu G AcioiiEss FAX N <br /> IlTY STAT <br /> 11.1AfyG ACKNQWI.I D �Mf NT: J, Iltu undcrsiErTed JaroJrcrtp of 17ubmus awncr, operator or authorizer) ngall of Ssult•,. <br /> �l nvwlccl6c that all site andlor Prajecl spceiiie ZNVWONMUYTALHCAL'1T1 DG-PARTMENT hourly cllal,ges assncialcd will,this paojccl of <br /> �6vity will be billed to me or Iny business as idcAli[IW on INS foNll. <br /> also certify That(have prepared ,l:is al)plicat'ton and dial lire walk to be pufurni" will I>c donc in aecoidancc.with all SAN)QAQwN <br /> our,rn' ordinance CodrJ, s,STAT• d I=CUERAL laws. <br /> All'?LICANT'SSLG^IhTU > : DATIE: <br /> k)LOVEXTY I bU51NJLaS OWNI;R 01't!ItATOR/ ANActic 0,riIzit.ALJrllD;.rcwrAcewr0 <br /> � <br /> If APPUCANT is ilor Me alLLtEg—PAH Ty proof of awlivrizirl ou to Sigli i,T squired rifle' Tl-f R17ATI N TQ RrLCA5U INFORMATION: W17en apPlicablc, 1, the owner or operu(ur of the Vt-olleriy loc:ltW at the <br /> evc site address, hcseby authorize the rcicasc of any and Al results, gcotechnicol data and/or envo-orrnnntaUaite s, rncttl <br /> Pilormal¢on to the Ltvy <br /> SAN JOAQViN COUNTY 1IRONMENT'AL.HUALTII DVAKI'MLNT as soon as it is available ar���} it;s <br /> �ovided Lo me or my rcprescniative. <br /> �PZ of SERY)CE REQUESTED: <br /> X111 NTS: 3 <br /> I <br /> QNN J)° Ep j�s R%Es <br /> iiENVIRONMEKTAti kiEmj"ONJ ION <br /> ! 'll <br /> PnOYED BY: EMPLOYEE M: <br /> y.. �- 7� � <br /> tSSIGT+E07 DATE: <br /> : -i - EMPLOYEE A: ' OATt:: <br /> ate 5 crvicc Complotali (ir already eompdetad): <br /> o f Amount: Paymoril Date, J- � Amaunl Paid ^ <br /> — <br /> yrnent Typo Invoice if Chock if <br /> Receivcu 13y: 7 <br /> I a�6-01 q25 t� <br /> r k'V(SE06.5-02 "ERVICE REQUEST rOn4i <br /> li <br />