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09/13/2007 TTIU 14t51 FAX -0fi63433 SSC EHD 0 1003/012 <br /> SAEN JOAQIJ, vOUNTY JENVIRONWNTAL HEALTIi PARTMENT <br /> SERVICE REQUEST <br /> Type of Bus ness or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 10 AERATOR <br /> GST 114- CHECK if BILLINGAoDRess� <br /> FACILITY NIA61f SC- „„q 1'2 <br /> VE'ADDRES;: "7� �-Act-Ftc A,yp Si'oC flan] X5247 <br /> 71D $treat Number Dlrectton I Striat Name ClIx Z. Coue <br /> HOME Or MAILING ADDREsS (If Differeot from$110 Address) �M�i�(,L t,or� 41 GH W,4,y <br /> I J 6treeL Nutn4er Street 113T.PL <br /> CITY STATE zip <br /> N O'Z-e1 r� (- G4 61,0 to 710 <br /> PHONaM Ext. APN p LANDUSEAPPJCATIQN# <br /> (562) �Cj <br /> PIID}iE#2 DST• HO3IJISTIIC7 LOCATION CODe <br /> CONTRACTOR/SERVICE RJEQUESTOR <br /> Rr=aut:sratc <br /> P� "f�.S`(,t ClracKftBtLLINGAooRess <br /> BUSINESS WIVE $�*�t CA4_I•f-D(� Grp,j �. PHONE <br /> SqL af24-�,r"81 3q� <br /> HOME or MAILING ADDRESS t 1 ��! E'n��tQ ?} FAX 9 <br /> J <br /> (� - <br /> ta2) a2-j � <br /> CITY -1 2 t! ILC STATE r zip �y �j 14 <br /> MILLING ,tCKNOWLEDGEMEN7': 1, the undersigned property or business owner, Operator or antIkorice(t agent of SRI C, <br /> neknowledg•:that all site andlor prcject specific ENVIRONMENTAL HI AL-ni Dr11ARTMEXI'llourly charges associated with this project <br /> Or activity sill be billed to the or my business as idenlitied on this Corm.. <br /> I also ces•dfj that l have prepared this application and tlsat tho work to be perfvrnied will be done in occordanec with all SAN JOAQ(JIN <br /> COUN'CY�)+',Imnarce C:acles•,.Sfpnrinrds,S'rAr�land Ffaal;itAt,laws. <br /> APPLICANI"SSIGNATURE: ') J <br /> 8 r7�I d 7 <br /> PH01'ISI1rYII4MIN914SOWNult© OrFILATORIMANAGM.R 0 (TrHISRAtrruostlrlsDAaltN'r WtO <br /> if A!'Nl,II.'.1N1'is+tag!Iyer L�li.1,L1rQ 1'AR7'Y,proal(tjrurfhor•iz�mllvn fn slg�f 1R YCQleircr! T1Ilc <br /> AU1'Fl RI;,A'r10N'1'0 12ELEASC,INFORMATIOM; When applicable, 1,the Owner or operates'of the property lowed nt the <br /> above site Isddress, hereby authorize the roleaso of any and all results, geotechnical data and/or envirDnmental/site assessment <br /> itifot-mation to[Ile SAN JOAQUIN COUNTY I NVIlWNMtiNTAI.WAI.I'li NPARTMEN'r as soon as It is available and at the Same time it is <br /> provided tome or my i-cpresen'ative. <br /> TYPE OF SERV CE REQUESTED: !�AC'T P at tai N GWT C LOSV 4ZE {(-Cl::lVi l} <br /> COMMENTS: <br /> AUG 2 4 ZOOr <br /> SAN JOAOUIN COUNTY <br /> ENV1t1UNMF:NTlAL <br /> itl�Al_l'II I')F.�NAFI'f MEN't` <br /> ACCEPTED 6s': EMPLOYEE#: DATE: <br /> ASSIGNEDTO r ' EMPLOYEE fie: 67 <br /> Date Sarvfcn Completed (If already completed): SEAVICECDDE: ��cG PIE:r)' <br /> Fee Amount: 2 , Amount Paid $ �g,_ 0 � Payment Data <br /> Payment Tyse ,��" Invoke 4 Cheek Al 0�Yi�� Received By: <br /> f <br /> END 46-02-025 <br /> REVISED 111'712003 SR FORM(Golders <br />