Laserfiche WebLink
SEP-02—_2_00_8_ 15:06 MID—VALLEY ENGINEERING 2095260803 P.03iO4 <br /> SAN JOAQLIIN CONJ y ENVIRONNIENTAI,FTxALTII MPARTMENT <br /> SI:rMfE REQUEST ^ <br /> Type of Business or Property j FACILrrY ID# SERVICE REQUEST# <br /> 64-P-1 <br /> OW NLK F OPERATDR._ <br /> T6MAJ r/�421L SCNaFF/LRP.,I?Y wacrs,ce cr+ecKlteaLa+aa.00N�s=❑ <br /> Fwi IFY NA41E �a c� <br /> SrcE ADDRESS I ! 1 Z- �62 <br /> 71 <br /> 1 trt[l Number ok crion 1 'W. Cir .Ip Cade <br /> HoilEorMAILING ADDRESS (If Different from Site Ad dress) <br /> rr S e" . time Number <br /> t,TM STATE GAJ LIP 95` 3 .f,1 <br /> � <br /> Pi1vNF a1 <br /> fn. APN# LANo USE APPI,ICAION 0 <br /> 12c9 1 R3 3�/3J 26 f- teo-lb f 17 -_ <br /> PNGHP�7 EA'. 130S DISTRICT LDGATRI CODE <br /> IZDyI 46 -6f15 <br /> CONTRACTOR I SERVICE REQUESTOR _ f� <br /> REQVESTDR CNEOKH BILLING APORESSr.-., <br /> E"r' <br /> DV SINESS NAME t <br /> PNONE$ <br /> nrp VAei.Fr CA&VAIEEyAlb Zol_1 S2�-rJz�y <br /> HOME nr MAILING ADDRESS FA%# <br /> jlj7 'L• ,$7-g y, (ZLD5 )yZG-eJ6 <br /> Gm r FOD37J STATE C^ Lm C(S31yf{ <br /> BILLING ACKNOWLEDGF,N1 T: 1, the undersigned property or business owner, operator or autholrized ngenl' of same, <br /> acknowledge that all Site andlor project specific CNVHtONMEIJTALHEACru DEP X3'MHNT hourly charges assoriatrd oith this project or <br /> activity will be billed to me or my business it�identified on this form <br /> I also ceTtify that I have prepared this app Ica on and that the work to he perfom <br /> red mill be dons in accotdance with all S 4N JDAQUIN <br /> CDL INTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> All PLICANI-S SIGNATURE. L Z DATF. _Z� c..Or?7 <br /> PROPERTY F$USIN855 OwryuR0 OPERATOR!ASANAAF'A C7 OTHER AU7HORr8O AC8NY NJ <br /> IfAYPLIGNT is not the&f.4b6:FAATC proof to to sign is required TIIfe <br /> AU'Ik(V R.l'GATION TORELEASE INFOkNIATION: When applicable,1,the o-Amer or operator of the propertc located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and)nr en•:imnmrntal•'aitc asscssrnent <br /> information to the SAN IDAQijrN COUNTY ENpiRnNMRNTAL RRALTH DEPARTASRNT as soon as it is available :Ind at i1w salle time it IS <br /> _provided io uic or my representative. <br /> TYPE of SERviGE REQUESTED: n` <br /> CnunERr s; Jz 9 � �-L'y�y.. �d"f✓,�' .. <br /> SEB <br /> SAN err;A01"t' <br /> fit FcI1:NvIFJON6IENTAL <br /> ALTH 771:FAq rA . <br /> ACCePilO LSY — _ — EMPLOYEE#: u DAT@: <br /> ASSIGNED TO: .6 7 'I .r ` / F14PLOVEE 0: � Cr• th.IR; <br /> Data Service Completed III already comoicle ) V V` SERVCC CODE: !^ PI L: r7 <br /> Fee Amount., 1 !Amount Pald t O, Payment Data �I <br /> Payment Typo I" invoice# ChecK# t , ' Roceivad By: tL`, <br /> EHD 46.112,025 Y?14f 5fgtrl� <br /> REVISED 11/172003 <br />