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ENVIRONMENTAL HcraI-2m <br /> 09/08/2004 16:14 4640138 L{vVIItONME`ITALLIEAT,TIIll"t'4RTMENT <br /> -_.;:SAN J OAQVIN •l`1TY <br /> SERVXCE REQUEST <br /> / SERVICE REQUEST 9 <br /> FACILITY ID <br /> Type of Business or Property p r —7 <br /> Z V v\V l I (-e / CHECK ifBauN_ G+�noR_0 <br /> O HER OPERATOR <br /> FprtM NAME ( LL I 21`I GVO <br /> 6ry Q -70 Z eon® <br /> SITE AptxtESs 13 i Name <br /> $tree(NWnbtt 'on ' <br /> Ho"of MAILING ADDRESS Of Different from Site Mdress) <br /> L ` STATE ZP <br /> Cm <br /> uNo USE{U'Pl1CA710N ft <br /> Fier. APN• <br /> POOH <br /> ijl�) 3� a 9-10 Bos DtSIVJCT LOCATION CODE <br /> Bn. <br /> PWWE12 <br /> (alb) c)-0 O <br /> - CONTRACTOR! SERVICE REQUESTOR alEacrce11wNcADO <br /> �F REQUESTOR <br /> pNotlE# <br /> BUSINESS NAME �^ ! Z,. FAX$ <br /> HOME or Mat.mG ADORE L 6 <br /> $TATE LP <br /> CITY �d o orator or authorized aLent of same, <br /> the undersigned property or business 0775cr, P associated with this project or <br /> e, <br /> ILL G ACKN0V,%EDGEM, : 1 hourly charges <br /> ac]atowledge that all site andior project speciuc EjtyntON;•16MAL IIFN-TH DrS!rATMF?'tr <br /> activity a i11 be billed 10 me a my business as identified on this form accordance with all SAN JOAQUIN <br /> pe Or this aL <br /> work to be perforDted will be done in <br /> I also certify that I haveFED laws. <br /> COUNTY Ordinance Codes,Standards,S [C� O <br /> 11 <br /> DATE: <br /> APPLICANT'S SIGNATURE: - Ong AUMORMM AGENT <br /> IIIANA4'btt Tills <br /> Paoesaty/Brnrngss OwNptl] xTT proojojauflwrization to sign is rega6ed at the <br /> IjAPPUCAN'f is r elle� tedO MATIOI`I' When applicable,J,the owner or operator of t �5°�A <br /> U HORl7.JMN TO RELEASE fNF R data and/or en+FgimF <br /> above site address, hereby authorize' the release of any and all D g azhniral soon as it is arailayle and at the same itme R is <br /> information to the SAN JOAQUIN COUNTY EWMONMFNTALFaA1'TB <br /> ARTMENT <br /> provided to one or my represcntaoiv 1 <br /> YTPE OE SERVICE REQUESTED: C.�^a^ E o 6w e/' C u.a fK I � o <br /> ENVIRONMENTAL <br /> COMMENT' loeycjoHEALTH DEPARTMENT <br /> � 2 () - 2ZgZ <br /> EMPLOYEE#: Date O <br /> ACCEPTED BY: DATE: <br /> EMPLOYEE 0; q/ <br /> AssIGNEDTO: Ok-4-54 WIQrk- pafCPl o PIE• <br /> $t RVICE CODE: 6(Q <br /> Date Service Completed (if already completed): Payment Date it <br /> Fee Amount: Cl3 op Amount Paid .3 '- <br /> Check# Received By'. <br /> Payment Type / Invoice# 1 'U <br /> SR FORM(Golden Rod) <br /> EHO 48-02425 <br /> REVISED 1111712003 <br /> SEP-08-2004 15:52 4640138 38: P.03 <br />