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Feb, 14. 03 1O: O2p THIT bvironmental Sastem A�58-1011 P• 1 <br /> SAN JOAQU1NTOUNTY ENVIKONMENTAL HEALTu DEVAICHVIENT <br /> SERVICE REQUEST /f/LL 33S <br /> Type of Business or Property FACILITY IDA SERVICE REQUEST If <br /> 645 ST�1rtro �( {Q �7 S2d <br /> OWNER OPERATOR <br /> 13 p W 65-F CbFl ST PjZO0UCT5 n LLC <br /> . . CNECKIIBILLINGAOORESS <br /> FACILITY NAME A Rv-D s:5 31: 6o -3-35- <br /> SITE <br /> o33SSITE ADDRESS ,Tgss �t A--� (+w-/ Q � STOGKTON <br /> street Number I Olrecilon I cily Zip Code <br /> HOMEOr MAILING ADDRESS (ii Different It, EnLTEVQ iOO l A1TE 1)R <br /> ' ' SIfCCI Nomb r r cl N me <br /> CITY LA „AL r STATE Cp ZJP 9btvZ3 <br /> PHONE If I 5 i r'E ExT. gpry 1 LAND USE APPLICATION 1 <br /> tavq) 9 48- 1;2LI38 <br /> PHONE12 r2P BOS DISTRICT LOCATION CODE <br /> mt ) ` Sal p', ' <br /> CONTRACTOR SERVICE RE'QUESTOR <br /> REOUESTOR Loat re-eS!-IOLLR CNECKIIljnuncAooness <br /> BUSINESS NAME PHONE✓♦ ExT' <br /> 'rK� IT ENII . SysT�V\A "t I& 8S4C- to9,o <br /> HOME or MAILING ADDRESS FAX A <br /> 3283 L-LLYu &iG DR . m(to) �5 - toll <br /> CITY J2 ANC("t o CO IZ06 V A STATE C tj ZIP q 5 -7 ,-(Z <br /> BILLING ING ACICNOWLEDCi NIENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project speciGC E•NVIItONMENTAL IIGALTH DCPAIITMENThourly charges associated with(his projector <br /> activity will be billed to ute or my business as identified on(his form. <br /> I also certify that I have prepared this application and that Ute work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slandards,STATE and FEI)WkAL laws. <br /> APPLICANT'S SIGNATURE: . ��i( �f1'11�i/Ai4 DATE: a- ) L4- 0 3 <br /> 1Yll01•HIITY I BUSINESS OWNISH❑ OPERATOR/MANAGER OTHER AurIloltlz D AGENT (1�1In14 K!i �4VI - <br /> If APPLICANT iS rlol(lie 111 ]fN�.lnroof of authorizatiatt(o sigh is regaired Title 0 <br /> AUTI-I0RI7ATION TO RLLLASH INFORMKPION: When applicable, I, the owner or operator of the properly located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/silt assmmillent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMDNTAL I-1UALTH DL'PARIMUNT as soon as it is available and at the same lime it is <br /> provided to me or my representative. <br /> TYPEOF SERVICE REQUESTED: <br /> COMMENTS: RE°LACe:O I MECHAN ICA I-. LeAt-4 'DE�7'I9E7c-7- OO <br /> Otis �9 $ `( l Tu 1z e)l K1eS R� <br /> 4 2pp3 <br /> r-ct.c.luuef tu.u:.eu. 7 r2e{a-Qere�etQ z rr-•1 Fro . 8 r <br /> Spool` `NEp NOMstON <br /> P� 4t1`i� <br /> APPROVED BY: EMPLOYEE 0: �� DATE: <br /> ASSIGNED TO: EMPLOYEE ,,a <br /> Date Service Complelod (11 already completed): SERVICE CODE: PIE: a3t�p <br /> Fee Amoun Amounl PaidPaymant Date <br /> Pavment Tvno Invnlr•n a .. — <br />