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.-...• w- FA WJAI a.vvamtrs /:SAY�lRV1Ve7G.1T1ALTae.wM II%A/LrAKI-MSN"1 <br /> SERVICE REQUEST <br /> Type Of Business or Property FACILITY R1 f SERVICE REQUEST 0 <br /> 6s � <br /> OWNER/OPERATOR <br /> -vioONAS. r+vLvv%CS CWXKItBILLING ADDRrsS0 <br /> FACLOYNAW NOL-mr-S PfLOPE$-Ty <br /> SITE ADDRESS 15496 1r$ L.oc-"Fot -tn FiSZ3-} <br /> Street Number Ma&I&vwzip <br /> HOME Of MMLDIO ADDREss (n Different tram Site Address) P.O . &X 10-L <br /> Sbe Number y <br /> Cnv Loc.Kt=f-OF'A STATE CA ZIP oISZ'J <br /> PI1IONEe1 En• APNe LAND USE APPLICATION <br /> (Zo91 �Z� 33sfo plq - Ido-oq + - (9 <br /> to= <br /> / <br /> P1gaE E1 �' a011CT LDOArioN CODE <br /> ( l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ff8f3� RAC40 CtFC1[lIBa.1ins ADDREss� <br /> BUSINESS NAME L1vt Da1LpP.r.J VIRON MEt.�T'AL RNN�t Err. <br /> yoq 3(o4-cs3�s <br /> HONE orMAILINo ADDREQS 40-, IN Otte- d6l..- FANtl <br /> CRY L_ODt STATE C.A ZIP GtS-7-4O <br /> BILLING ACKNOWLEDGEMENT: I, the widersi®aeii property or buMess owner, operator or authorbed agent of same, <br /> aclmowledge that all site and/or project specific ENVIRONMENIAJ,HEAL-M DEPARTIMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as idciatificd on this fomJ. <br /> I also cortify that I have prepared this application and that the work W be perfwmcd will be dOW ill acc rcbmce with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL s. / <br /> APPLICANT'S SIGNATU3kE: DATE; 2-/ �.—4-D, <br /> PW*taTY/xVsD es&OwKM0 cw%xA"x t%AM.AGU 0r1MII AUMQRrzm AGENT❑ <br /> /f APPLICANT rs nor the BrLUNG P,rATY.pwsf e/'ozrfiartifetien to sJgm[I rtgrbN rind <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 enviremnemal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVLRONMENTAL REALTT(DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICEREQEeTEn: 9-r,%Ar-W SOIL_ pA,(MENT <br /> q �� �Z <br /> CoNraas: RECEI <br /> 3 v AUG 10 2012 <br /> EWROnMENNrAL <br /> �/iL�/�� HEnLTM oeanRrP=rr <br /> ACCEPTED BY: EMPLOYEE R: DATE: ( r7 <br /> AsSIONED To: I✓C.1' Cd EMPLOtlEEf: DATE: <br /> Data Service Completed ("already completed): SW—=CODE: SZZ PIE: 2� <br /> Fee Amount: ZSU Amount Paid 9ST , 0 ED Peymant Daft p Z <br /> Payment Type Invoice r Check t l`9'Z, Received By: <br /> EHD 48.02.025 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />